Provider Demographics
NPI:1518287531
Name:CHONIC PAIN MANAGEMENT CLINIC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CHONIC PAIN MANAGEMENT CLINIC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-610-3776
Mailing Address - Street 1:210 S GRAND AVE STE 315
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4284
Mailing Address - Country:US
Mailing Address - Phone:626-610-3776
Mailing Address - Fax:714-242-2077
Practice Address - Street 1:10630 DOWNEY AVE STE 102
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3463
Practice Address - Country:US
Practice Address - Phone:626-610-3776
Practice Address - Fax:714-242-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43746207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty