Healthcare Provider Details

I. General information

NPI: 1205120375
Provider Name (Legal Business Name): PACIFIC RHEUMATOLOGY MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 W LA VETA AVE SUITE 105
ORANGE CA
92868-3901
US

IV. Provider business mailing address

805 W LA VETA AVE SUITE 105
ORANGE CA
92868-3901
US

V. Phone/Fax

Practice location:
  • Phone: 814-248-1006
  • Fax:
Mailing address:
  • Phone: 814-248-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberC54349
License Number StateCA

VIII. Authorized Official

Name: BEHNAM KHALEGHI
Title or Position: MD/OWNER
Credential: MD
Phone: 814-248-1006