Provider Demographics
NPI:1912385451
Name:PACIFIC EMPIRE PHYSICAL MEDICINE AND HEALTHCARE INC
Entity Type:Organization
Organization Name:PACIFIC EMPIRE PHYSICAL MEDICINE AND HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:HALATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-464-9880
Mailing Address - Street 1:4590 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3980
Mailing Address - Country:US
Mailing Address - Phone:909-464-9880
Mailing Address - Fax:909-591-4720
Practice Address - Street 1:4590 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3980
Practice Address - Country:US
Practice Address - Phone:909-464-9880
Practice Address - Fax:909-591-4720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-17
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92433208D00000X
CAPA18558364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty