Provider Demographics
NPI:1497134969
Name:CENTRAL VALLEY PAIN MANAGEMENT AND WELLNESS CLINIC INC
Entity Type:Organization
Organization Name:CENTRAL VALLEY PAIN MANAGEMENT AND WELLNESS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-448-3848
Mailing Address - Street 1:311 PARK PLACE BLVD FL 5
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 MABLE AVE # SUITEB2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1120
Practice Address - Country:US
Practice Address - Phone:813-448-3848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51949332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site