Basic Information
| Provider Information | |||||||||
| NPI: | 1407155229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC HEALTH SERVICES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PREMIERE SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5021 HIGHWAY 280 | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059827878 | ||||||||
| FaxNumber: | 2059827848 | ||||||||
| Practice Location | |||||||||
| Address1: | 5021 HIGHWAY 280 | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059827878 | ||||||||
| FaxNumber: | 2059827848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2011 | ||||||||
| LastUpdateDate: | 05/25/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIERPOINT | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2059827878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT, MSPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.