Provider Demographics
NPI:1023043551
Name:PACIFIC WEST SPECIALTIES, LLC
Entity type:Organization
Organization Name:PACIFIC WEST SPECIALTIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-335-8649
Mailing Address - Street 1:PO BOX 11525
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1525
Mailing Address - Country:US
Mailing Address - Phone:909-335-8649
Mailing Address - Fax:909-335-1994
Practice Address - Street 1:101 E REDLANDS BLVD STE 212
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4724
Practice Address - Country:US
Practice Address - Phone:909-335-8649
Practice Address - Fax:909-335-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX I.D.