MEDICARE: PACIFICA SL MCMINNVILLE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1316307440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFICA SL MCMINNVILLE LLC

Provider Business Mailing Address
First Line	:	1775 HANCOCK ST
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-2034
Country	:	US
Telephone Number	:	619-296-9000
Fax Number	:	619-296-9090

Provider Business Practice Location Address
First Line	:	320 SW HILL RD
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-9133
Country	:	US
Telephone Number	:	503-472-3509
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	DEEPAK ISRANI
Credential	:
Telephone Number	:	619-296-9000

Provider Enumeration Date	:	03/02/2016
Last Update Date	:	03/02/2016

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