Provider Demographics
NPI:1487881397
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: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:515-285-6487
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:515-285-6487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA770692261QH0700X, 261QX0100X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0807321Medicaid
IA0807321Medicaid