1225405863 NPI number — PRO CARE PAIN CLINIC

Table of content: (NPI 1225405863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225405863 NPI number — PRO CARE PAIN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO CARE PAIN CLINIC
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:
1225405863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 S VIRGIL AVE
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90005-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-487-1025
Provider Business Mailing Address Fax Number:
888-450-1242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 S VIRGIL AVE
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90005-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-487-1025
Provider Business Practice Location Address Fax Number:
888-450-1242
Provider Enumeration Date:
08/31/2015

Additional Information

Authorized Official

Authorized Official Last Name:
YOON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
213-487-1025

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC16014 , 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)

  • Identifier: 08312015926198 . This is a "ACUPUNCTURE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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