Provider Demographics
NPI:1043493570
Name:PAIN DIAGNOSIS & TREATMENT INC., A MEDICAL CLINIC
Entity Type:Organization
Organization Name:PAIN DIAGNOSIS & TREATMENT INC., A MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-857-7400
Mailing Address - Street 1:210 S GRAND AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4205
Mailing Address - Country:US
Mailing Address - Phone:626-857-7400
Mailing Address - Fax:626-857-7404
Practice Address - Street 1:10630 DOWNEY AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3463
Practice Address - Country:US
Practice Address - Phone:562-861-5170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43746207LP2900X
CAA020970207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A437461Medicaid
CA00A437461Medicaid
CAWA20970EMedicare PIN
CAE01555Medicare UPIN
CAWA43746KMedicare PIN
CAWA43746IMedicare PIN
CAWA20970CMedicare PIN