Provider Demographics
NPI:1811353998
Name:PACIFIC MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PACIFIC MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WRUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-873-0733
Mailing Address - Street 1:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1140
Mailing Address - Country:US
Mailing Address - Phone:808-873-0733
Mailing Address - Fax:
Practice Address - Street 1:95 LONO AVE STE 105
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1610
Practice Address - Country:US
Practice Address - Phone:808-873-0733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC-726111NX0100X
HIRN24680364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty
No111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Multi-Specialty