Basic Information
| Provider Information | |||||||||
| NPI: | 1861407637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSMART PACIFIC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PACIFIC HOSPITAL OF LONG BEACH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2776 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908062613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625951911 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2776 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908062613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625951911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANEDO | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5629972414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 930000117 | CA | N | Hospital Units | Psychiatric Unit | 282N00000X | 930000117 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT30277G | 05 | CA | MEDICAID | HSD30277G | 05 | CA | MEDICAID | HSM30277G | 05 | CA | MEDICAID | HSC30277G | 05 | CA | MEDICAID | LTC55264F | 05 | CA | MEDICAID | LTC70011F | 05 | CA | MEDICAID | 213381100 | 01 | CA | US DEPT OF LABOR | OTHER | ZZT40277G | 05 | CA | MEDICAID |