Provider Demographics
NPI:1205027869
Name:PACIFIC PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:PACIFIC PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-951-1234
Mailing Address - Street 1:27725 SANTA MARGARITA PKWY
Mailing Address - Street 2:SUITE 221
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6704
Mailing Address - Country:US
Mailing Address - Phone:949-951-1234
Mailing Address - Fax:
Practice Address - Street 1:27725 SANTA MARGARITA PKWY
Practice Address - Street 2:SUITE 221
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6704
Practice Address - Country:US
Practice Address - Phone:949-951-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities