1154631943 NPI number — RANCHO MIRAGE PAIN MANAGEMENT INC

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 1154631943 NPI number — RANCHO MIRAGE PAIN MANAGEMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANCHO MIRAGE PAIN MANAGEMENT INC
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:
1154631943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 3023
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO MIRAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92270-1092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-202-1919
Provider Business Mailing Address Fax Number:
760-202-1982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71780 SAN JACINTO DRIVE
Provider Second Line Business Practice Location Address:
SUITE 83
Provider Business Practice Location Address City Name:
RANCHO MIRAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92270-1092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-202-1919
Provider Business Practice Location Address Fax Number:
760-202-1982
Provider Enumeration Date:
10/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON M.D
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-202-1919

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  G061216 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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