Provider Demographics
NPI:1144241779
Name:PACIFIC OCEAN MEDICAL CLINIC
Entity Type:Organization
Organization Name:PACIFIC OCEAN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MANOUCHEHR
Authorized Official - Middle Name:
Authorized Official - Last Name:RASHTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-268-7707
Mailing Address - Street 1:PO BOX 49998
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-0998
Mailing Address - Country:US
Mailing Address - Phone:310-268-7707
Mailing Address - Fax:310-268-7708
Practice Address - Street 1:12340 SANTA MONICA BLVD STE 302
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-0348
Practice Address - Country:US
Practice Address - Phone:310-268-7707
Practice Address - Fax:310-268-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A401670Medicaid
CAW10628Medicare PIN