NPIMap

Organization Active NPI

Pacific Diagnostics

  • Family Medicine Physician
  • Garden Grove, CA
National Provider Identifier
1306881297
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
20A4401 Issued in CA
Legal business name
PACIFIC DIAGNOSTICS
Practice address
13312 Euclid St
Garden Grove, CA 92843-2514
Phone
(714) 741-0622
Fax
(714) 741-0623
NPI assigned
Jun 17, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Bryn Jarald Henderson, D.O.NPI 1447296694
Title
President/Owner
Phone
(714) 741-0622

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X 20A4401 CA Primary

Addresses

Primary practice location

13312 Euclid St
Garden Grove, CA 92843-2514

Mailing address

17853 Santiago Blvd
#107-489
Villa Park, CA 92861-4113
Phone (714) 741-0622

Other identifiers 2

IdentifierTypeStateIssuer
00AX44011MedicaidCA
00AX44010MedicaidCA

National Provider Directory

National Provider Directory

Locations

11180 Warner Ave
Ste 361
Fountain Vly, CA 92708
Phone (714) 327-1625

9726 Foothill Blvd
Rch Cucamonga, CA 91730
Phone (909) 987-4262

17853 Santiago Blvd
Ste 107489
Villa Park, CA 92861

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150502400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1306881297",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17853 SANTIAGO BLVD",
            "address_2": "#107-489",
            "city": "VILLA PARK",
            "state": "CA",
            "postal_code": "928614113",
            "telephone_number": "714-741-0622",
            "fax_number": "714-741-0623"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13312 EUCLID ST",
            "city": "GARDEN GROVE",
            "state": "CA",
            "postal_code": "928432514",
            "telephone_number": "714-741-0622",
            "fax_number": "714-741-0623"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PACIFIC DIAGNOSTICS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-17",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "HENDERSON",
        "authorized_official_first_name": "BRYN",
        "authorized_official_middle_name": "JARALD",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "714-741-0622",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "CA",
            "license": "20A4401",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00AX44011",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00AX44010",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Garden Grove, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.