Provider Demographics
NPI:1932131653
Name:PACIFIC CREST MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PACIFIC CREST MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-388-4316
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-8630
Mailing Address - Country:US
Mailing Address - Phone:949-388-4316
Mailing Address - Fax:949-388-4319
Practice Address - Street 1:34052 LA PLZ
Practice Address - Street 2:SUITE 101
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2587
Practice Address - Country:US
Practice Address - Phone:949-388-4316
Practice Address - Fax:949-388-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13226AMedicare PIN
CAW13226JMedicare PIN
CAW13226Medicare PIN
CAW13226LMedicare PIN
CAW13226BMedicare PIN