=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720944655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFICSOURCE PACE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2026
-----------------------------------------------------
Last Update Date | 01/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 INTERNATIONAL WAY STE B104
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-6013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 458-544-0400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70071
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97475-0104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-214-2526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. ELLEN MAE GARCIA
-----------------------------------------------------
Credential | MPH
-----------------------------------------------------
Telephone | 425-214-2526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------