Provider Demographics
NPI:1932474798
Name:PACIFIC WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PACIFIC WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:670-233-4646
Mailing Address - Street 1:PO BOX 10003
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950-8903
Mailing Address - Country:US
Mailing Address - Phone:670-233-4646
Mailing Address - Fax:670-233-4648
Practice Address - Street 1:MARIANAS HEALTH LLC BUILDING STE#201 GHIYEGHI
Practice Address - Street 2:ST. SAN JOSE
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-8903
Practice Address - Country:US
Practice Address - Phone:670-233-4646
Practice Address - Fax:670-233-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP20142-0002-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAEO039AMedicare Oscar/Certification