Provider Demographics
NPI:1083080717
Name:PACIFIC RESTORATIVE CENTER
Entity Type:Organization
Organization Name:PACIFIC RESTORATIVE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-623-9803
Mailing Address - Street 1:1456 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-800-7633
Mailing Address - Fax:707-843-3485
Practice Address - Street 1:1456 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 404
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-800-7633
Practice Address - Fax:707-843-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical