Healthcare Provider Details

I. General information

NPI: 1962504761
Provider Name (Legal Business Name): PACIFICASPINE,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 S VICTORIA AVE STE 220 SUITE # 220
VENTURA CA
93003-6151
US

IV. Provider business mailing address

1752 S VICTORIA AVE STE 220 SUITE # 220
VENTURA CA
93003-6151
US

V. Phone/Fax

Practice location:
  • Phone: 805-585-0231
  • Fax: 805-482-7940
Mailing address:
  • Phone: 805-585-0231
  • Fax: 805-482-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK JOHN SIMONSON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 805-585-0231