Healthcare Provider Details

I. General information

NPI: 1265785323
Provider Name (Legal Business Name): PACIFIC HEALTHCARE IPA MEDICAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AIRPORT PLAZA DR SUITE 150
LONG BEACH CA
90815-1271
US

IV. Provider business mailing address

5000 AIRPORT PLAZA DR SUITE 150
LONG BEACH CA
90815-1271
US

V. Phone/Fax

Practice location:
  • Phone: 562-766-2000
  • Fax: 562-766-2008
Mailing address:
  • Phone: 562-766-2000
  • Fax: 562-766-2008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: FAUSTINO BERNADETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 562-446-2999