Provider Demographics
NPI:1205007606
Name:PACIFIC CLINICS
Entity Type:Organization
Organization Name:PACIFIC CLINICS
Other - Org Name:PACIFIC CLINICS TAY-YUCCA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:626-254-5000
Mailing Address - Street 1:800 S SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-6853
Mailing Address - Country:US
Mailing Address - Phone:626-254-5000
Mailing Address - Fax:626-294-1077
Practice Address - Street 1:58945 BUSINESS CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7307
Practice Address - Country:US
Practice Address - Phone:760-228-9657
Practice Address - Fax:760-369-6258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36D1Medicaid
CADA767DMedicare PIN