Provider Demographics
NPI:1306275854
Name:PACIFIC SPINE AND WELLNESS PC
Entity type:Organization
Organization Name:PACIFIC SPINE AND WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:EBERHART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-724-1800
Mailing Address - Street 1:3300 IRVINE AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3108
Mailing Address - Country:US
Mailing Address - Phone:949-724-1800
Mailing Address - Fax:949-724-1811
Practice Address - Street 1:3300 IRVINE AVE STE 307
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3108
Practice Address - Country:US
Practice Address - Phone:949-724-1800
Practice Address - Fax:949-724-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26382111N00000X
CAA709672085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH20460Medicare UPIN
CA26382Medicare UPIN