MEDICARE: PACIFIC EMPIRE PHYSICAL MEDICINE AND HEALTHCARE 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	364SF0001X	Family Health Clinical Nurse Specialist	PA18558	CA
2	208D00000X	General Practice Physician	A92433	CA

General Provider Information

NPI Number	:	1912385451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC EMPIRE PHYSICAL MEDICINE AND HEALTHCARE INC

Provider Business Mailing Address
First Line	:	4590 RIVERSIDE DR
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-3980
Country	:	US
Telephone Number	:	909-464-9880
Fax Number	:	909-591-4720

Provider Business Practice Location Address
First Line	:	4590 RIVERSIDE DR
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-3980
Country	:	US
Telephone Number	:	909-464-9880
Fax Number	:	909-591-4720

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. ALI HALATI
Credential	:	MD
Telephone Number	:	909-464-9880

Provider Enumeration Date	:	05/17/2015
Last Update Date	:	09/21/2015

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