Basic Information
| Provider Information | |||||||||
| NPI: | 1376015966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC GARDENS MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 17TH ST STE 201D | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953541249 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 21530 PIONEER BLVD | ||||||||
| Address2: | |||||||||
| City: | HAWAIIAN GARDENS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907162608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628600401 | ||||||||
| FaxNumber: | 5629245871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2018 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT, CFO | ||||||||
| AuthorizedOfficialTelephone: | 2092876308 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PACIFIC GARDENS MEDICAL CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
No ID Information.