Healthcare Provider Details

I. General information

NPI: 1457586521
Provider Name (Legal Business Name): PACIFIC COAST MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 DORADO PL
ROLLING HILLS ESTATES CA
90274-4213
US

IV. Provider business mailing address

4 DORADO PL
ROLLING HILLS ESTATES CA
90274-4213
US

V. Phone/Fax

Practice location:
  • Phone: 800-678-3127
  • Fax: 800-929-8557
Mailing address:
  • Phone: 800-678-3127
  • Fax: 800-929-8557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA84067
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084H0002X
TaxonomyHospice and Palliative Medicine (Psychiatry & Neurology) Physician
License NumberA84067
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA84067
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA84067
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberA84067
License Number StateCA

VIII. Authorized Official

Name: DR. LAWRENCE VERNON TUCKER
Title or Position: CEO/DIRECTOR
Credential: M.D.
Phone: 800-678-3127