Provider Demographics
NPI:1386828275
Name:PACIFIC CLINICS
Entity Type:Organization
Organization Name:PACIFIC CLINICS
Other - Org Name:PACIFIC CLINICS RIVERSIDE TBS EXPANSION PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:626-254-5000
Mailing Address - Street 1:800 S SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-6853
Mailing Address - Country:US
Mailing Address - Phone:626-254-5000
Mailing Address - Fax:626-294-1077
Practice Address - Street 1:13800 HEACOCK ST
Practice Address - Street 2:SUITES C236 & C210
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3339
Practice Address - Country:US
Practice Address - Phone:951-653-0819
Practice Address - Fax:951-656-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33HXMedicaid