Provider Demographics
NPI:1043211147
Name:PACIFIC PAIN TREATMENT CENTER
Entity Type:Organization
Organization Name:PACIFIC PAIN TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRAMES
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:415-567-1219
Mailing Address - Street 1:2000 VAN NESS AVE
Mailing Address - Street 2:SUITE #402
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-3023
Mailing Address - Country:US
Mailing Address - Phone:415-567-1219
Mailing Address - Fax:415-567-2534
Practice Address - Street 1:2000 VAN NESS AVE
Practice Address - Street 2:SUITE #402
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-3023
Practice Address - Country:US
Practice Address - Phone:415-567-1219
Practice Address - Fax:415-567-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23073208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0069910Medicaid
CAZZZ43183ZOtherBLUE SHEILD
CAG23073OtherBLUE CROSS
CAMMM00088MMedicare ID - Type Unspecified
CAGR0069910Medicaid