Provider Demographics
NPI:1619380896
Name:PACIFIC BREAST INSTITUTE MEDICAL GROUP
Entity Type:Organization
Organization Name:PACIFIC BREAST INSTITUTE MEDICAL GROUP
Other - Org Name:COSMETIC SURGERY ASSOCIATES MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OSSAMA
Authorized Official - Middle Name:DEAYA
Authorized Official - Last Name:ASCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-629-6417
Mailing Address - Street 1:20160 E LIMECREST DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3945
Mailing Address - Country:US
Mailing Address - Phone:909-629-6417
Mailing Address - Fax:909-629-4755
Practice Address - Street 1:350 VINTON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3000
Practice Address - Country:US
Practice Address - Phone:909-629-6417
Practice Address - Fax:909-629-4755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:O D ASCHA,MD APC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26396261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical