Healthcare Provider Details

I. General information

NPI: 1386352466
Provider Name (Legal Business Name): PACIFICA FOUNDATION LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N VERMONT AVE STE 407
LOS ANGELES CA
90027-6086
US

IV. Provider business mailing address

1300 N VERMONT AVE STE 407
LOS ANGELES CA
90027-6086
US

V. Phone/Fax

Practice location:
  • Phone: 323-913-4524
  • Fax: 323-913-4826
Mailing address:
  • Phone: 323-913-4524
  • Fax: 800-245-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS LONG
Title or Position: PRESIDENT
Credential:
Phone: 323-913-4914