1861407637 NPI number — HEALTHSMART PACIFIC INC

Table of content: JESSICA NICOLE ANDERSON (NPI 1710596366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861407637 NPI number — HEALTHSMART PACIFIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSMART PACIFIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PACIFIC HOSPITAL OF LONG BEACH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861407637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2776 PACIFIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90806-2613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-595-1911
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2776 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90806-2613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-595-1911
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANEDO
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
562-997-2414

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  930000117 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 930000117 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZT30277G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSD30277G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSM30277G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HSC30277G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LTC55264F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LTC70011F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213381100 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZT40277G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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