Healthcare Provider Details

I. General information

NPI: 1073712790
Provider Name (Legal Business Name): PACIFIC NEURO DIAGNOSTIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2361B E PALMDALE BLVD
PALMDALE CA
93550-4910
US

IV. Provider business mailing address

6800 LINCOLN AVE SUITE 200
BUENA PARK CA
90620-4162
US

V. Phone/Fax

Practice location:
  • Phone: 661-540-0824
  • Fax:
Mailing address:
  • Phone: 714-995-5400
  • Fax: 714-995-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SIM C. HOFFMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 661-540-0824