Provider Demographics
NPI:1104864909
Name:PAIN CLINIC OF MONTEREY BAY
Entity Type:Organization
Organization Name:PAIN CLINIC OF MONTEREY BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:POREE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-724-6111
Mailing Address - Street 1:55 PENNY LANE
Mailing Address - Street 2:STE 103
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:1555 SOQUEL DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065
Practice Address - Country:US
Practice Address - Phone:831-462-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22870ZMedicare ID - Type Unspecified