Provider Demographics
NPI:1942616990
Name:PACIFIC INTEGRATIVE MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:PACIFIC INTEGRATIVE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEELIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEFFEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-453-8393
Mailing Address - Street 1:2400 BROADWAY
Mailing Address - Street 2:SUITE 520
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3030
Mailing Address - Country:US
Mailing Address - Phone:310-453-8393
Mailing Address - Fax:310-453-8696
Practice Address - Street 1:2400 BROADWAY
Practice Address - Street 2:SUITE 520
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3030
Practice Address - Country:US
Practice Address - Phone:310-453-8393
Practice Address - Fax:310-453-8696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28098111NN0400X
CAA1087512081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91109Medicare UPIN