Provider Demographics
NPI:1336113489
Name:PACIFIC CANCER MEDICAL CENTER INC
Entity Type:Organization
Organization Name:PACIFIC CANCER MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-999-1465
Mailing Address - Street 1:1801 W ROMNEYA DR
Mailing Address - Street 2:STE #203
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1830
Mailing Address - Country:US
Mailing Address - Phone:714-999-1465
Mailing Address - Fax:714-999-1701
Practice Address - Street 1:1801 W ROMNEYA DR
Practice Address - Street 2:STE #203
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1830
Practice Address - Country:US
Practice Address - Phone:714-999-1465
Practice Address - Fax:714-999-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45465174400000X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093300Medicaid
CA6209110001Medicare NSC
CAW13175Medicare ID - Type UnspecifiedMEDICARE GRP. PROVIDER #