Healthcare Provider Details

I. General information

NPI: 1811488760
Provider Name (Legal Business Name): PACIFIC HEALTH MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 LONG BEACH BLVD STE 200
LONG BEACH CA
90807
US

IV. Provider business mailing address

3711 LONG BEACH BLVD STE 200
LONG BEACH CA
90807-3319
US

V. Phone/Fax

Practice location:
  • Phone: 562-980-0555
  • Fax:
Mailing address:
  • Phone: 562-980-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HAROLD ISEKE
Title or Position: OWNER
Credential: DC
Phone: 562-980-0555