Provider Demographics
NPI:1508391293
Name:PACIFIC SURGICAL SPECIALIST LLC
Entity Type:Organization
Organization Name:PACIFIC SURGICAL SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-462-8668
Mailing Address - Street 1:2345 E 8TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2800
Mailing Address - Country:US
Mailing Address - Phone:619-609-4186
Mailing Address - Fax:619-479-1006
Practice Address - Street 1:2345 E 8TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2800
Practice Address - Country:US
Practice Address - Phone:619-609-4186
Practice Address - Fax:619-479-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89447261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty