Provider Demographics
NPI:1225011976
Name:PACIFIC CREST MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PACIFIC CREST MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-597-0124
Mailing Address - Street 1:32341 GOLDEN LANTERN
Mailing Address - Street 2:SUITE M
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5343
Mailing Address - Country:US
Mailing Address - Phone:949-597-0124
Mailing Address - Fax:949-597-0124
Practice Address - Street 1:32341 GOLDEN LANTERN
Practice Address - Street 2:SUITE M
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5343
Practice Address - Country:US
Practice Address - Phone:949-597-0124
Practice Address - Fax:949-597-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC037249207Q00000X
CAC040002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty