Provider Demographics
NPI:1306881297
Name:PACIFIC DIAGNOSTICS
Entity type:Organization
Organization Name:PACIFIC DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYN
Authorized Official - Middle Name:JARALD
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-741-0622
Mailing Address - Street 1:17853 SANTIAGO BLVD
Mailing Address - Street 2:#107-489
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92861-4113
Mailing Address - Country:US
Mailing Address - Phone:714-741-0622
Mailing Address - Fax:714-741-0623
Practice Address - Street 1:13312 EUCLID ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2514
Practice Address - Country:US
Practice Address - Phone:714-741-0622
Practice Address - Fax:714-741-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX44011Medicaid
CA00AX44010Medicaid
CAC64508Medicare UPIN
CAW16585AMedicare ID - Type Unspecified
CAZZZ32541ZMedicare ID - Type Unspecified
CA00AX44010Medicaid