Provider Demographics
NPI:1316200256
Name:GREAT PACIFIC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GREAT PACIFIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-434-0900
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:265 POSADA LN
Practice Address - Street 2:SUITE B
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4056
Practice Address - Country:US
Practice Address - Phone:805-434-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT PACIFIC MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-15
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site