Provider Demographics
NPI:1578993242
Name:ARROYO VISTA ADVANCED PAIN SPECIALISTS, INC.
Entity Type:Organization
Organization Name:ARROYO VISTA ADVANCED PAIN SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LANA LOUIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WANIA-GALICIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-222-4549
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:865 PATRIOT DR
Practice Address - Street 2:SUITE 201A
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3407
Practice Address - Country:US
Practice Address - Phone:805-222-4549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARROYO VISTA ADVANCED PAIN SPECIALISTS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80078332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site