Provider Demographics
NPI:1326285180
Name:E C AMERICA
Entity Type:Organization
Organization Name:E C AMERICA
Other - Org Name:CAROL JACKSON, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-651-3415
Mailing Address - Street 1:1835 NEWPORT BLVD STE A109
Mailing Address - Street 2:#384
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5007
Mailing Address - Country:US
Mailing Address - Phone:949-651-3415
Mailing Address - Fax:
Practice Address - Street 1:361 HOSPITAL RD
Practice Address - Street 2:SUITE 325
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3522
Practice Address - Country:US
Practice Address - Phone:949-651-3415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3824261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG50085OtherMEDICARE PTAN