MEDICARE: PACIFIC MEDICAL RESOURCES, 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
1	302F00000X	Exclusive Provider Organization

General Provider Information

NPI Number	:	1437508132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC MEDICAL RESOURCES, INC.

Provider Business Mailing Address
First Line	:	1102 SOUTH MAIN STREET
Second Line	:	SUITE #3
City	:	FORT BRAGG
State	:	CA
Zip	:	95437
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 S MAIN ST
Second Line	:	SUITE #3
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-5305
Country	:	US
Telephone Number	:	707-964-2000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EMMA CARTER
Credential	:
Telephone Number	:	707-964-2000

Provider Enumeration Date	:	06/03/2016
Last Update Date	:	06/03/2016

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