Basic Information
Provider Information | |||||||||
NPI: | 1326248204 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PACIFIC CLINICS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PACIFIC CLINICS FOOTHILL SCHOOL | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 S SANTA ANITA AVE | ||||||||
Address2: |   | ||||||||
City: | ARCADIA | ||||||||
State: | CA | ||||||||
PostalCode: | 910066853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262545000 | ||||||||
FaxNumber: | 6262941077 | ||||||||
Practice Location | |||||||||
Address1: | 4490 CORNISHON AVE | ||||||||
Address2: |   | ||||||||
City: | LA CANADA | ||||||||
State: | CA | ||||||||
PostalCode: | 910113243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189494758 | ||||||||
FaxNumber: | 8189494757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2007 | ||||||||
LastUpdateDate: | 04/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANDEL | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 6262545000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 7704 | 05 | CA |   | MEDICAID |