Provider Demographics
NPI:1326237058
Name:PACIFIC COAST WOMEN'S CENTER
Entity Type:Organization
Organization Name:PACIFIC COAST WOMEN'S CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:AHDOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-700-8300
Mailing Address - Street 1:2461 SANTA MONICA BLVD # 635
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2138
Mailing Address - Country:US
Mailing Address - Phone:310-315-1436
Mailing Address - Fax:
Practice Address - Street 1:2121 WILSHIRE BLVD STE 302
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5743
Practice Address - Country:US
Practice Address - Phone:310-315-1436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA55892174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A558920Medicaid
CAG67069Medicare UPIN