=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629874847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFICO ENTERPRISE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 SCHILLINGER RD N STE 102
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-5060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-388-9055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 SCHILLINGER RD N STE 102
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36608-5060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-388-9055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | NIA MASEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 251-388-9055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 246XS1301X
-----------------------------------------------------
Taxonomy Name | Sonography Specialist/Technologist Cardiovascular
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------