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NPI Code Detail

MEDICARE: PINE PARK HEALTH, INC

MEDICARE: PINE PARK HEALTH, INC
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
1207Q00000XFamily Medicine Physician
2207QA0505XAdult Medicine Physician
3207QG0300XGeriatric Medicine (Family Medicine) Physician
4363A00000XPhysician Assistant
5363L00000XNurse Practitioner
6363LA2100XAcute Care Nurse Practitioner
7363LA2200XAdult Health Nurse Practitioner
8363LF0000XFamily Nurse Practitioner
9363LG0600XGerontology Nurse Practitioner
10363LP2300XPrimary Care Nurse Practitioner
11207R00000XInternal Medicine Physician

General Provider Information

NPI Number : 1346879848
Entity Type Code : Organization
Provider Name (Legal Business Name) : PINE PARK HEALTH, INC
Provider Business Mailing Address
First Line : PO BOX 511250
Second Line :
City : LOS ANGELES
State : CA
Zip : 90051-7805
Country : US
Telephone Number : 510-929-1400
Fax Number : 510-929-1414
Provider Business Practice Location Address
First Line : 1901 4TH ST STE 201
Second Line :
City : BERKELEY
State : CA
Zip : 94710-1986
Country : US
Telephone Number : 510-929-1400
Fax Number : 510-929-1414
Authorized Official
Title or Position : CREDENTIALING COORDINATOR
Name : STEPHANIE VANZEE
Credential :
Telephone Number : 469-401-8820
Provider Enumeration Date : 04/06/2020
Last Update Date : 02/04/2025

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