Provider Demographics
NPI:1447418108
Name:PAIN REHAB CARE MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:PAIN REHAB CARE MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TUYEN
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-258-3229
Mailing Address - Street 1:1865 ALUM ROCK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1865 ALUM ROCK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1396
Practice Address - Country:US
Practice Address - Phone:408-258-3229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA460240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24212ZMedicare PIN