Provider Demographics
NPI:1043977655
Name:PACIFIC CREST HEALTHCARE INDEPENDENT PROVIDER ASSOCIATION, INC.
Entity type:Organization
Organization Name:PACIFIC CREST HEALTHCARE INDEPENDENT PROVIDER ASSOCIATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:833-724-4111
Mailing Address - Street 1:2601 AIRPORT DR STE 250
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6141
Mailing Address - Country:US
Mailing Address - Phone:833-724-4111
Mailing Address - Fax:
Practice Address - Street 1:2601 AIRPORT DR STE 250
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6141
Practice Address - Country:US
Practice Address - Phone:833-724-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-18
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC4080636OtherCALIFORNIA SECRETARY OF STATE CORPORATION