Provider Demographics
NPI:1053707182
Name:PACIFIC COAST MEDICAL SUPPLY
Entity type:Organization
Organization Name:PACIFIC COAST MEDICAL SUPPLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-706-4552
Mailing Address - Street 1:218 CHICAGO AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5292
Mailing Address - Country:US
Mailing Address - Phone:562-706-4552
Mailing Address - Fax:877-733-3462
Practice Address - Street 1:1704 W MANCHESTER AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3063
Practice Address - Country:US
Practice Address - Phone:562-706-4552
Practice Address - Fax:877-733-3462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6449380001Medicare NSC