Basic Information
| Provider Information | |||||||||
| NPI: | 1184171290 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINNICALE PAIN CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 HOYT LANE | ||||||||
| Address2: | |||||||||
| City: | WAPATO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989519753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093883388 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3730 PLAZA WAY STE C6100 | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993382718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2016 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | SALVADOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5093883388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.