Provider Demographics
NPI:1144564469
Name:PACIFIC BREAST CARE CENTER
Entity Type:Organization
Organization Name:PACIFIC BREAST CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEYDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-2986
Mailing Address - Street 1:1640 NEWPORT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3786
Mailing Address - Country:US
Mailing Address - Phone:949-515-3544
Mailing Address - Fax:949-515-3644
Practice Address - Street 1:1640 NEWPORT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-515-3544
Practice Address - Fax:949-515-3644
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000148261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty