=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184654972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN JOSEPH PACK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 12/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 ADMIRALTY WAY SUITE 356
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-822-8584
-----------------------------------------------------
Fax | 310-822-9924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 928
-----------------------------------------------------
City | MANHATTAN BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-822-8584
-----------------------------------------------------
Fax | 310-822-9924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G078330
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------