=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386352466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFICA FOUNDATION LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2022
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 N VERMONT AVE STE 407
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-913-4524
-----------------------------------------------------
Fax | 323-913-4826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 N VERMONT AVE STE 407
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-913-4524
-----------------------------------------------------
Fax | 323-913-4826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMIE YOO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-913-4914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------