PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP. , NPI 1023428521 — LOS ANGELES (CA)

NPI 1023428521

5+ Years Experience Organization

PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.

05.06.2014
PROVIDER ENUMERATION DATE
10.05.2015
LAST UPDATE DATE
1023428521
NPI NUMBER

About PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.

Parent organization: PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP..

PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP. is a provider established in LOS ANGELES, CA. The NPI number of PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP. is 1023428521 and was assigned on 05.06.2014. The practitioners primary taxonomy code is: 332900000X with license number: G44674 CA .

Mailing address

  • City: LOS ANGELES
  • State: CA
  • Postal code: 900771726
  • Phone: 3109434180
  • Fax: 8884318819
  • Address: 2980 N BEVERLY GLEN CIR
  • Address 2: SUITE 100

Primary Practice Address

  • Region : LOS ANGELES, CA
  • NPI : 1023428521
  • Phone : 8185185980
  • Fax : 8183372049
  • Postalcode : 900485426
  • Address : 6310 SAN VICENTE BLVD SUITE 220

Provider taxonomy - Non-Pharmacy Dispensing Site

  • Taxonomy code: 332900000X
  • License number: G44674
  • License state: CA

The taxonomy is the primary taxonomy (there can be only one per NPI record).

Taxonomy description: A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.)

Contacts:

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  • PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
  • Address : 6310 SAN VICENTE BLVD SUITE 220
  • Region : LOS ANGELES, CA
  • NPI : 1023428521
  • Phone : 8185185980
  • Fax : 8183372049
  • Postalcode : 900485426

Authorized official :

{:AUTHORIZED_OFFICIAL_FIRST_NAME:} {:AUTHORIZED_OFFICIAL_MIDDLE_NAME:} {:AUTHORIZED_OFFICIAL_LAST_NAME:}
  • Phone : 8185185980
  • Title or position : MEDICAL DIRECTOR
  • Credentials : M.D.

Reference NPI Information. Full replica of the CMS (NPPES) NPI record

Field Name Value
Provider First Line Business Practice Location Address6310 SAN VICENTE BLVD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location AddressSUITE 220
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City NameLOS ANGELES
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State NameCA
The State or Province name in the location address of the provider being identified.
Provider Business Practice Location Address Postal Code900485426
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Telephone Number8185185980
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number8183372049
The fax number associated with the location address of the provider being identified.
NPI1023428521
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
Healthcare Provider Taxonomy 1332900000X
A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.)
Provider Enumeration Date05.06.2014
The date the provider was assigned a unique identifier (assigned an NPI).
Last Updated10.05.2015
The date that a record was last updated or changed.
Entity TypeOrganization
Code describing the type of health care provider that is being assigned an NPI. Codes are:
  • 1 = (Person): individual human being who furnishes health care;
  • 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Is Organization SubpartY
The "Is the organization a subpart?" question must be answered. If the organization is a subpart, the Parent Organization Legal Business Name (LBN) and Parent Organization Taxpayer Identification Number (TIN) fields must be completed. The Parent Organization LBN and TIN fields can only be completed if the answer to the subpart question is Yes. Many organization health care providers who apply for NPIs are not legal entities themselves but are parts of other organization health care providers that are legal entities (the "parents"). Here are three examples of organization health care providers that may be considered subparts and may apply for NPIs if so directed by their "parents": (1) The psychiatric unit in a hospital is not a legal entity but is part of the hospital (the "parent"), which is a legal entity. The legal entity must obtain an NPI. The psychiatric unit is an example of a subpart that could have its own NPI if the hospital determines that it should. (2) A group practice that is not a sole proprietorship has a main location and could have other offices in different locations, but each office is not a separate legal entity; instead, each office is part of the corporation (the "parent") which is a legal entity. The offices are examples of subparts that could have their own NPIs if the main location determines that they should. (3) A pharmacy fills prescriptions for patients whose physicians have prescribed medications for them and may also rent or sell durable medical equipment to patients whose physicians have ordered such equipment for them. Neither the pharmacy line of business nor the DME line of business represent legal entities; instead, both lines of business are part of an organization (the "parent") that is a legal entity. Each line of business represents a different Healthcare Provider Taxonomy or area of specialization that often submits its own electronic claims to health plans. The "parent"-we don"t know who the parent is in this example-must ensure that each subpart that submits its own claims to health plans has its own NPI.
Provider Organization Name (Legal Business Name)PACIFIC REJUVENATION MEDICAL, A PROFESSIONAL CORP.
Provide organization name (legal business name used to file tax returns with the IRS). The Organization Name field allows the following special characters: ampersand, apostrophe, "at" sign, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
Provider First Line Business Mailing Address2980 N BEVERLY GLEN CIR
The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Second Line Business Mailing AddressSUITE 100
The second line mailing address of the provider being identified. This data element may contain the same information as "Provider second line location address".
Provider Business Mailing Address City NameLOS ANGELES
The City name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address City name".
Provider Business Mailing Address State NameCA
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code900771726
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Telephone Number3109434180
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Provider Business Mailing Address Fax Number8884318819
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
Authorized Official Last NameGOODLOE
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First NameLYNN
The first name of the authorized official
Authorized Official Middle NameJ.
The middle name of the authorized official
Authorized Official Title or PositionMEDICAL DIRECTOR
The title or position of the authorized official
Authorized Official Name Prefix TextDR.
Authorized Official Name Prefix Text
Authorized Official Credential TextM.D.
Authorized Official Credential Text
Authorized Official Telephone Number8185185980
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code #1332900000X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 1Non-Pharmacy Dispensing Site
A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.)
Provider License Number 1G44674
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 1CA
Healthcare Provider Primary Taxonomy Switch 1Y
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
X

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