ISC SAN PEDRO BLASSER CLINIC (NPI# 1821130113) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1821130113 |
| Entity Type | Organization |
| Organization Name | ISC SAN PEDRO BLASSER CLINIC |
| Practice Address |
1001 S Seaside Ave San Pedro CA 90731-7333 |
| Practice Telephone | 3107327500 |
| Practice Fax Number | 3107327519 |
| Mailing Telephone | 3107327500 |
| Mailing Fax Number | 3107327519 |
| Enumeration Date | 2007-02-13 |
| Last Update Date | 2020-08-22 |
| Authorized Official Name | MR. MARVIN ANTONIO PENA (CLINIC SUPERVISOR) |
| Authorized Official Telephone | 3107327500 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 261QM1100X |
Clinic/Center Specialization: Military/U.S. Coast Guard Outpatient |
Ambulatory Health Care Facilities |
| Street Address |
1001 S SEASIDE AVE |
| City | SAN PEDRO |
| State | CA |
| Zip Code | 90731-7333 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1932185220 | Thomas Lee Bostwick | Emergency Medicine | 1001 S Seaside Ave, San Pedro, CA 90731-7333 | 2005-12-19 |
| 1336484781 | Nancy M Hejde | Physician Assistant | 1001 S Seaside Ave, San Pedro, CA 90731-7333 | 2012-12-11 |
| 1992972186 | Bartholomew Jay Gaska | Technician, Other | 1001 S Seaside Ave, Bldg. 23, San Pedro, CA 90731-7333 | 2008-05-15 |
| 1972796324 | Stella Wisner | Dentist | 1001 S Seaside Ave, San Pedro, CA 90731-7333 | 2007-08-20 |
| 1811039001 | David Romero | Technician, Other | 1001 S Seaside Ave, San Pedro, CA 90731-7333 | 2007-02-13 |
| 1831253376 | Sara Marie Mindell | Registered Nurse | 1001 S Seaside Ave, Bldg 23, San Pedro, CA 90731-7333 | 2006-12-20 |
| 1366536898 | Paul E Kender | Physical Therapist | 1001 S Seaside Ave, Bldg #23, San Pedro, CA 90731-7333 | 2006-10-02 |
| 1205933066 | Us Coast Guard Finance Center | Military/U.S. Coast Guard Pharmacy | 1001 S Seaside Ave, San Pedro, CA 90731-7333 | 2006-09-20 |
| 1528038932 | Nohea L Villanueva | Technician, Other | 1001 S Seaside Ave, Isc San Pedro Medical, San Pedro, CA 90731-7333 | 2006-01-26 |
| 1275512733 | Christopher Warren Podratz | Specialist/Technologist, Other | 1001 S Seaside Ave, San Pedro, CA 90731-7333 | 2006-01-12 |
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| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1962009464 | Jyoti Patel | Optometrist | 1701 Gaffey St., San Pedro, CA 90731 | 2020-10-07 |
| 1518513183 | Churairat Maffei | Technician | 1305 S Patton Ave, San Pedro, CA 90731 | 2019-08-09 |
| 1326692898 | Lori Marie Kroeker | Counselor | 235 W. 9th St, San Pedro, CA 90731 | 2019-08-01 |
| 1366960783 | Maria Elena Newcomer Dds Inc | Dentist | 847 W. 9th St., San Pedro, CA 90731 | 2017-09-06 |
| 1255875944 | Raymond J Mazuchowski Jr. | Dentist | 697 S Gaffery St, San Pedro, CA 90731 | 2016-12-14 |
| 1700235108 | Redina J Williams | Counselor | 559 W, 9th Street, San Pedro, CA 90731 | 2016-06-07 |
| 1649697764 | Leilani M. Sharpe | Psychiatry & Neurology | 222 W 6th St Ste 400, San Pedro, CA 90731 | 2014-03-26 |
| 1134418882 | Neema Rukiya Hardeman | Pediatrics | 2400 S Pacific Ave Bldg 30, San Pedro, CA 90731 | 2011-04-04 |
| 1477878148 | Karla Vanesa Cehua | Dental Assistant | 423n. Meyler St., San Pedro, CA 90731 | 2010-04-06 |
| 1023258183 | Deborah Anne Allsup | Acupuncturist | 732 W. 9th Street, #202, San Pedro, CA 90731 | 2009-03-03 |
| Find all providers in zip 90731 | ||||
| Taxonomy Code | 261QM1100X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Military/U.S. Coast Guard Outpatient |
| The Defense Health Program or U.S. Coast Guard funded "fixed" facilities or distinct parts of a facility, providing outpatient medical and dental services, primarily for Uniformed Services beneficiaries. A "fixed" facility is a non-temporary, non-deployed facility. It includes mobile specialty units such as Magnetic Resonance Imaging (MRI) units that may furnish services at the "fixed" facility. It includes, as examples, the institutional portion of outpatient encounters (except Ambulatory Procedure Visits), supplies issued (e.g., glasses, ostomy supplies, crutches), and radiology and laboratory studies. Does not include items issued directly to a patient from an outpatient pharmacy or patient transport. |
| Notes: Source: TRICARE Management Activity Uniform Business Office User’s Guide [1/1/2005: title modified, definition added; 7/1/2006 title modified, definition modified] |
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| 1083028989 | Weed Army Community Hospital | Clinic/Center | Bldg 189 Ave B, Fort Irwin, CA 92310 | 2014-06-18 |
| 1891109799 | Weed Army Community Hospital | Clinic/Center | Ave B Bldg R190, Warrior Care Center, Fort Irwin, CA 92310 | 2014-06-18 |
| 1871832394 | Branch Medical Clinic Area 62 | Clinic/Center | Bldg 620306 8th Street, Camp Pendleton, CA 92055 | 2013-02-04 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.