Provider Demographics
NPI:1588697247
Name:PACIFICA HEALTH SERVICES LLC
Entity type:Organization
Organization Name:PACIFICA HEALTH SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:WOLNERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, FASCP
Authorized Official - Phone:515-285-2559
Mailing Address - Street 1:4911 SW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-4487
Mailing Address - Country:US
Mailing Address - Phone:515-285-2559
Mailing Address - Fax:
Practice Address - Street 1:4911 SW 19TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-4487
Practice Address - Country:US
Practice Address - Phone:515-285-2559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0085310400000X
IA770692313M00000X, 314000000X
IA261QP2000X, 261QH0700X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0807321Medicaid
IA0807321Medicaid