Healthcare Provider Details

I. General information

NPI: 1720944655
Provider Name (Legal Business Name): PACIFICSOURCE PACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 INTERNATIONAL WAY STE B104
SPRINGFIELD OR
97477-6013
US

IV. Provider business mailing address

PO BOX 70071
SPRINGFIELD OR
97475-0104
US

V. Phone/Fax

Practice location:
  • Phone: 458-544-0400
  • Fax:
Mailing address:
  • Phone: 425-214-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. ELLEN MAE GARCIA
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH
Phone: 425-214-2526