=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083080717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC RESTORATIVE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2015
-----------------------------------------------------
Last Update Date | 05/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1456 PROFESSIONAL DRIVE SUITE 404
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-800-7633
-----------------------------------------------------
Fax | 707-843-3485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1456 PROFESSIONAL DRIVE SUITE 404
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-800-7633
-----------------------------------------------------
Fax | 707-843-3485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JASON POPE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 707-623-9803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------