Provider Demographics
NPI:1124210497
Name:PACIFIC ADHC INC.
Entity Type:Organization
Organization Name:PACIFIC ADHC INC.
Other - Org Name:DAYLIGHT SF VALLEY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONG
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-776-8700
Mailing Address - Street 1:5562 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-776-8700
Mailing Address - Fax:818-776-8789
Practice Address - Street 1:5562 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-776-8700
Practice Address - Fax:818-776-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
CA060000692261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADV70259GMedicaid
CAADV70259GMedicaid