Provider Demographics
NPI:1114089257
Name:PACIFIC RIDGE MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PACIFIC RIDGE MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-422-2589
Mailing Address - Street 1:25401 CABOT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5513
Mailing Address - Country:US
Mailing Address - Phone:949-768-4850
Mailing Address - Fax:949-215-9630
Practice Address - Street 1:25401 CABOT RD STE 101
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5513
Practice Address - Country:US
Practice Address - Phone:949-768-4850
Practice Address - Fax:949-215-9630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFIC RIDGE MEDICAL ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-14
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2425685261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15812Medicare ID - Type Unspecified