Basic Information
| Provider Information | |||||||||
| NPI: | 1740434356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE PAIN CENTER, PS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LYNX HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8524 W GAGE BLVD | ||||||||
| Address2: | BLDG A-1 BOX 319 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993368241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
| FaxNumber: | 5099871977 | ||||||||
| Practice Location | |||||||||
| Address1: | 7401 W HOOD PLACE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993363400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
| FaxNumber: | 5099871977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 07/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5095788846 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1092681 | 05 | WA | MEDICAID |