Provider Demographics
NPI:1841416435
Name:PACIFIC COAST HEART CENTER A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:PACIFIC COAST HEART CENTER A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:THEARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-495-0800
Mailing Address - Street 1:30131 TOWN CENTER DR
Mailing Address - Street 2:SUITE 237
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677
Mailing Address - Country:US
Mailing Address - Phone:949-495-0800
Mailing Address - Fax:949-495-0805
Practice Address - Street 1:30131 TOWN CENTER DR
Practice Address - Street 2:SUITE 237
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677
Practice Address - Country:US
Practice Address - Phone:949-495-0800
Practice Address - Fax:949-495-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC50353AOtherMEDICARE INDIVIDUAL PTAN
W16824Medicare UPIN