Healthcare Provider Details

I. General information

NPI: 1831707199
Provider Name (Legal Business Name): PACIFIC INTEGRATIVE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 SANTA MONICA BLVD # 101
SANTA MONICA CA
90404-2312
US

IV. Provider business mailing address

2232 SANTA MONICA BLVD # 101
SANTA MONICA CA
90404-2312
US

V. Phone/Fax

Practice location:
  • Phone: 310-393-2225
  • Fax: 310-393-3321
Mailing address:
  • Phone: 310-393-2225
  • Fax: 310-393-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN ANATOL VASILEV
Title or Position: PROGRAM SPARE HOLDER - VP
Credential: MD
Phone: 310-393-2225