Basic Information
| Provider Information | |||||||||
| NPI: | 1265727762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NAVARRO PAIN CONTROL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2452 FENTON STREET | ||||||||
| Address2: | C101 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919144543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196005309 | ||||||||
| FaxNumber: | 6196554700 | ||||||||
| Practice Location | |||||||||
| Address1: | 2452 FENTON STREET | ||||||||
| Address2: | C101 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919144543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196005309 | ||||||||
| FaxNumber: | 6196554700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | NAVARRO | ||||||||
| AuthorizedOfficialFirstName: | ROSA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6196005309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | C53858 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1265727762 IN PROCES | 05 | CA | MEDICAID |