Provider Demographics
NPI:1124004114
Name:SAN DIMAS PAIN MANAGEMENT MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:SAN DIMAS PAIN MANAGEMENT MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-294-4866
Mailing Address - Street 1:125 WHEELER AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3220
Mailing Address - Country:US
Mailing Address - Phone:626-294-4866
Mailing Address - Fax:626-294-4872
Practice Address - Street 1:125 WHEELER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3220
Practice Address - Country:US
Practice Address - Phone:626-294-4866
Practice Address - Fax:626-294-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53113208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14408Medicare ID - Type Unspecified
F89498Medicare UPIN