Provider Demographics
NPI:1013458975
Name:PACIFICA COSMETIC SURGERY CENTER, A MEDICAL CORP
Entity Type:Organization
Organization Name:PACIFICA COSMETIC SURGERY CENTER, A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-640-9570
Mailing Address - Street 1:280 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7526
Mailing Address - Country:US
Mailing Address - Phone:949-640-9570
Mailing Address - Fax:949-640-9569
Practice Address - Street 1:280 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7526
Practice Address - Country:US
Practice Address - Phone:949-640-9570
Practice Address - Fax:949-640-9569
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFICA COSMETIC SURGERY CENTER, A MEDICAL CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28839261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922165703OtherNPI OF PROVIDER
CA00G69421Medicare PIN
CAE57869Medicare UPIN