Provider Demographics
NPI:1497193650
Name:PENINSULA PAIN RELIEF CENTER
Entity Type:Organization
Organization Name:PENINSULA PAIN RELIEF CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-478-9788
Mailing Address - Street 1:5050 STATE HIGHWAY 303 NE
Mailing Address - Street 2:SUITE A101
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-3629
Mailing Address - Country:US
Mailing Address - Phone:360-478-9788
Mailing Address - Fax:360-405-6255
Practice Address - Street 1:5050 STATE HIGHWAY 303 NE
Practice Address - Street 2:SUITE A101
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-3629
Practice Address - Country:US
Practice Address - Phone:360-478-9788
Practice Address - Fax:360-405-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty