Healthcare Provider Details

I. General information

NPI: 1912385451
Provider Name (Legal Business Name): PACIFIC EMPIRE PHYSICAL MEDICINE AND HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 RIVERSIDE DR
CHINO CA
91710-3980
US

IV. Provider business mailing address

4590 RIVERSIDE DR
CHINO CA
91710-3980
US

V. Phone/Fax

Practice location:
  • Phone: 909-464-9880
  • Fax: 909-591-4720
Mailing address:
  • Phone: 909-464-9880
  • Fax: 909-591-4720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberPA18558
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA92433
License Number StateCA

VIII. Authorized Official

Name: MR. ALI HALATI
Title or Position: DIRECTOR
Credential: MD
Phone: 909-464-9880