Healthcare Provider Details

I. General information

NPI: 1083080717
Provider Name (Legal Business Name): PACIFIC RESTORATIVE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1456 PROFESSIONAL DRIVE SUITE 404
PETALUMA CA
94954
US

IV. Provider business mailing address

1456 PROFESSIONAL DRIVE SUITE 404
PETALUMA CA
94954
US

V. Phone/Fax

Practice location:
  • Phone: 707-800-7633
  • Fax: 707-843-3485
Mailing address:
  • Phone: 707-800-7633
  • Fax: 707-843-3485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASON POPE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 707-623-9803