Healthcare Provider Details

I. General information

NPI: 1225011976
Provider Name (Legal Business Name): PACIFIC CREST MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32341 GOLDEN LANTERN SUITE M
LAGUNA NIGUEL CA
92677-5343
US

IV. Provider business mailing address

32341 GOLDEN LANTERN SUITE M
LAGUNA NIGUEL CA
92677-5343
US

V. Phone/Fax

Practice location:
  • Phone: 949-597-0124
  • Fax: 949-597-0124
Mailing address:
  • Phone: 949-597-0124
  • Fax: 949-597-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC040002
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC037249
License Number StateCA

VIII. Authorized Official

Name: MRS. KARLA J ANDERSON
Title or Position: MEDICAL BILLER
Credential:
Phone: 949-597-0124