Provider Demographics
NPI:1871833715
Name:PACIFIC WAVECREST MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PACIFIC WAVECREST MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:GHAZALA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-284-0111
Mailing Address - Street 1:2500 E BALL RD
Mailing Address - Street 2:STE 200
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 E BALL RD
Practice Address - Street 2:STE 200
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5054
Practice Address - Country:US
Practice Address - Phone:714-284-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43843174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty