=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164619987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFICA MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 09/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24192 MIMOSA DR
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-677-7523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24192 MIMOSA DR
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-677-7523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEVIN POLUCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-677-7523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2756954
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------