Healthcare Provider Details

I. General information

NPI: 1437381589
Provider Name (Legal Business Name): PACIFIC COAST WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LYNN RD
THOUSAND OAKS CA
91360-1935
US

IV. Provider business mailing address

2100 LYNN RD
THOUSAND OAKS CA
91360-1935
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-7406
  • Fax: 805-557-4583
Mailing address:
  • Phone: 805-777-7406
  • Fax: 805-557-4583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DARYOUSH JADALI
Title or Position: PRESIDENT
Credential: MD
Phone: 805-777-7406