Basic Information
| Provider Information | |||||||||
| NPI: | 1578703484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAIN MANAGEMENT CARE & CHIROPRACTIC, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917730457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099719334 | ||||||||
| FaxNumber: | 9099719654 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 S AZUSA AVE STE B6 | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917914088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269178706 | ||||||||
| FaxNumber: | 6269178759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2009 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | MATIN | ||||||||
| AuthorizedOfficialFirstName: | MAHMOUD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6269178706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 23316DC | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.