MEDICARE: HEIDI RAE GARCIA PAC

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	363A00000X	Physician Assistant	13904	CA

General Provider Information

NPI Number	:	1508853136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI RAE GARCIA PAC

Provider Business Mailing Address
First Line	:	3228 W 154TH ST
Second Line	:
City	:	GARDENA
State	:	CA
Zip	:	90249-4016
Country	:	US
Telephone Number	:	310-715-2185
Fax Number	:

Provider Business Practice Location Address
First Line	:	1141 W REDONDO BEACH BLVD
Second Line	:	SUITE 104
City	:	GARDENA
State	:	CA
Zip	:	90247-3586
Country	:	US
Telephone Number	:	310-538-9400
Fax Number	:	310-538-0101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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