Basic Information
| Provider Information | |||||||||
| NPI: | 1912376005 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA PAIN CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109434180 | ||||||||
| FaxNumber: | 8884318819 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 CHERRY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983104208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604159110 | ||||||||
| FaxNumber: | 3604790265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2015 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | PEXTON | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3604159110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENINSULA PAIN CLINIC, PLLC | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 332900000X | OP60339103 | WA | N | Suppliers | Non-Pharmacy Dispensing Site | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.