Healthcare Provider Details

I. General information

NPI: 1023043551
Provider Name (Legal Business Name): PACIFIC WEST SPECIALTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E REDLANDS BLVD STE 212
REDLANDS CA
92373-4724
US

IV. Provider business mailing address

PO BOX 11525
SAN BERNARDINO CA
92423-1525
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-8649
  • Fax: 909-335-1994
Mailing address:
  • Phone: 909-335-8649
  • Fax: 909-335-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD ROTAN
Title or Position: C.F.O.
Credential:
Phone: 909-335-8649