Healthcare Provider Details

I. General information

NPI: 1487881397
Provider Name (Legal Business Name): PACIFICA HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 SW 19TH ST
DES MOINES IA
50315-4487
US

IV. Provider business mailing address

4911 SW 19TH ST
DES MOINES IA
50315-4487
US

V. Phone/Fax

Practice location:
  • Phone: 515-285-2559
  • Fax: 515-285-6487
Mailing address:
  • Phone: 515-285-2559
  • Fax: 515-285-6487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number770692
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number770692
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number770692
License Number StateIA

VIII. Authorized Official

Name: ALLEN PHILIP WOLNERMAN
Title or Position: OWNER
Credential: RPH, FASCP
Phone: 515-285-2559