1043965163 NPI number — PAIN MANAGEMENT & REJUVENATION CLINIC USA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043965163 NPI number — PAIN MANAGEMENT & REJUVENATION CLINIC USA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT & REJUVENATION CLINIC USA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043965163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 ORANGEBURGH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD TAPPAN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07675-7499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-714-4683
Provider Business Mailing Address Fax Number:
201-742-0084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1209 SUMMIT AVE UNIT 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07307-3170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-714-4683
Provider Business Practice Location Address Fax Number:
201-742-0084
Provider Enumeration Date:
02/16/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PEGUERO
Authorized Official First Name:
CLARICIO
Authorized Official Middle Name:
DECASTRO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
551-204-2543

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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