Provider Demographics
NPI:1043559081
Name:YAKIMA RIVER PAIN MANAGEMENT PS
Entity Type:Organization
Organization Name:YAKIMA RIVER PAIN MANAGEMENT PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAVERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-962-2273
Mailing Address - Street 1:109 S WATER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3061
Mailing Address - Country:US
Mailing Address - Phone:509-962-2273
Mailing Address - Fax:509-962-2270
Practice Address - Street 1:109 S WATER ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3061
Practice Address - Country:US
Practice Address - Phone:509-962-2273
Practice Address - Fax:509-962-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty