Provider Demographics
NPI:1558316984
Name:LA PHYSIATRISTS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LA PHYSIATRISTS PROFESSIONAL CORPORATION
Other - Org Name:LOS ANGELES PAIN & WELLNESS INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:DAMIAN
Authorized Official - Last Name:MINOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-482-1046
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-482-1046
Mailing Address - Fax:213-482-4811
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-482-1046
Practice Address - Fax:213-482-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19985Medicare PIN