Healthcare Provider Details

I. General information

NPI: 1013360676
Provider Name (Legal Business Name): SOUTH PACIFIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD
RNCINO CA
91364
US

IV. Provider business mailing address

16260 VENTURA BLVD
ENCINO CA
91436-2203
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1977
  • Fax:
Mailing address:
  • Phone: 818-986-1977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberAT1195
License Number StateCA

VIII. Authorized Official

Name: KAREN SHAPIRO COBAIN
Title or Position: PTA
Credential: PTA
Phone: 818-577-9410