Basic Information
| Provider Information | |||||||||
| NPI: | 1538497813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFICA HEALTH & WELLNESS CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5524 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925094515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512489113 | ||||||||
| FaxNumber: | 9512489115 | ||||||||
| Practice Location | |||||||||
| Address1: | 5524 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925094515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512489113 | ||||||||
| FaxNumber: | 9512489115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2009 | ||||||||
| LastUpdateDate: | 09/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | VU | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | THUAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7143935800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | A64785 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 363A00000X | PA16671 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA10031 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.