Provider Demographics
NPI:1538466651
Name:ADVANCE PAIN MANAGEMENT GROUP
Entity Type:Organization
Organization Name:ADVANCE PAIN MANAGEMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHUBHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-366-0474
Mailing Address - Street 1:P.O. BOX 8000
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91327-8000
Mailing Address - Country:US
Mailing Address - Phone:818-366-0474
Mailing Address - Fax:818-474-7530
Practice Address - Street 1:11177 TAMPA AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-2254
Practice Address - Country:US
Practice Address - Phone:818-366-0474
Practice Address - Fax:818-474-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization