Provider Demographics
NPI:1558541870
Name:ALESIA PAIN TREATMENT CENTER, A MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ALESIA PAIN TREATMENT CENTER, A MEDICAL GROUP, INC.
Other - Org Name:PENINSULA PAIN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:TRUONG
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:408-368-1889
Mailing Address - Street 1:2450 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100 B
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1706
Mailing Address - Country:US
Mailing Address - Phone:650-493-7246
Mailing Address - Fax:650-493-7248
Practice Address - Street 1:2450 EL CAMINO REAL
Practice Address - Street 2:SUITE 100 B
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1706
Practice Address - Country:US
Practice Address - Phone:650-493-7246
Practice Address - Fax:650-493-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9059207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty