Provider Demographics
NPI:1023253739
Name:PACIFIC DRIVE MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:PACIFIC DRIVE MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-756-7800
Mailing Address - Street 1:999 E PACIFIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3033
Mailing Address - Country:US
Mailing Address - Phone:801-756-7800
Mailing Address - Fax:801-756-7805
Practice Address - Street 1:999 E PACIFIC DRIVE
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3033
Practice Address - Country:US
Practice Address - Phone:801-756-7800
Practice Address - Fax:801-756-7805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDP1898OtherRAILROAD MEDICARE PTAN
UTDP1898OtherRAILROAD MEDICARE PTAN
UT6423380001Medicare NSC