Provider Demographics
NPI:1639139827
Name:PACIFIC HEART INSTITUTE
Entity Type:Organization
Organization Name:PACIFIC HEART INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORALEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-238-1792
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:280W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-7678
Mailing Address - Fax:310-449-6958
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:280W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-829-7678
Practice Address - Fax:310-449-6958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10022550OtherLABORATORY ECHOCARDIOGRAPHY
CAB1393570420OtherLABORATORY NUCLEAR
CAGR0050330Medicaid
CAW3968Medicare ID - Type Unspecified