Basic Information
| Provider Information | |||||||||
| NPI: | 1760998744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC GARDENS MEDICAL CENTER, LLC | ||||||||
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| OtherOrganizationName: | PACIFIC GARDENS MEDICAL CENTER, HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 17TH ST STE 201D | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953541249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095051035 | ||||||||
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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: | 12/28/2017 | ||||||||
| LastUpdateDate: | 12/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | GIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2095051035 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PACIFIC GARDENS MEDICAL CENTER, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | Y | Nursing & Custodial Care Facilities | Hospice, Inpatient |
No ID Information.