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General NPI Number Information
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NPI Number | 1942593918
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Entity Type | Organization
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Legal Business Name | PACIFIC INTERVENTIONAL VASCULAR ACCESS CENTER MEDICAL CORPORATION
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Dates
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Enumeration Date | 05/24/2011
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 6076 BRISTOL PKWY STE 108
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City | CULVER CITY
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State | CA
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Zip | 90230-6600
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Country | US
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Telephone | 310-348-9604
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Fax |
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Provider Business Mailing Address
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Address Line | 40 VALLEY STREAM PKWY SUITE 100
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City | MALVERN
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State | PA
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Zip | 19355-1407
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Country | US
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Telephone | 610-644-8900
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | SPENCER BROWN
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Credential | MD
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Telephone | 310-348-9604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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