Basic Information
| Provider Information | |||||||||
| NPI: | 1861436008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC HEARING , INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11645 WILSHIRE BLVD | ||||||||
| Address2: | SUITE # 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104775558 | ||||||||
| FaxNumber: | 3104777281 | ||||||||
| Practice Location | |||||||||
| Address1: | 11645 WILSHIRE BLVD | ||||||||
| Address2: | SUITE # 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104775558 | ||||||||
| FaxNumber: | 3104777281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRAZER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104775558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | AU.D., PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | W16009 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GAU000791 | 05 | CA | MEDICAID |