1619994365 NPI number — TEMECULA VALLEY PAIN MEDICAL GROUP

Table of content: (NPI 1619994365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619994365 NPI number — TEMECULA VALLEY PAIN MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEMECULA VALLEY PAIN MEDICAL GROUP
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:
6
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:
1619994365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27475 YNEZ RD # 295
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92591-4612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-894-5000
Provider Business Mailing Address Fax Number:
951-296-1098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28078 BAXTER RD
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92563-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-894-5000
Provider Business Practice Location Address Fax Number:
951-296-1098
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
VANCE
Authorized Official Middle Name:
ZACHARY
Authorized Official Title or Position:
PRESIDENTCEO
Authorized Official Telephone Number:
951-894-5000

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , 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: ZZZ09959Z . This is a "BLUE SHIELD ID #1" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ09960Z . This is a "BLUE SHIELD ID #2" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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