Healthcare Provider Details

I. General information

NPI: 1164896403
Provider Name (Legal Business Name): PACIFIC GROVE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BROCKTON AVE
RIVERSIDE CA
92506-1862
US

IV. Provider business mailing address

PO BOX 31001-2130
PASADENA CA
91110-2130
US

V. Phone/Fax

Practice location:
  • Phone: 800-992-0901
  • Fax:
Mailing address:
  • Phone: 213-412-1973
  • Fax: 213-412-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN HEYDT
Title or Position: CHIEF EXECUTIVE OFICER
Credential: M.D.
Phone: 714-456-2986