Provider Demographics
NPI:1619994365
Name:TEMECULA VALLEY PAIN MEDICAL GROUP
Entity Type:Organization
Organization Name:TEMECULA VALLEY PAIN MEDICAL GROUP
Other - Org Name:UNIVERSITY SPINE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENTCEO
Authorized Official - Prefix:
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:ZACHARY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-894-5000
Mailing Address - Street 1:27475 YNEZ RD # 295
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4612
Mailing Address - Country:US
Mailing Address - Phone:951-894-5000
Mailing Address - Fax:951-296-1098
Practice Address - Street 1:28078 BAXTER RD
Practice Address - Street 2:SUITE 128
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1402
Practice Address - Country:US
Practice Address - Phone:951-894-5000
Practice Address - Fax:951-296-1098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ09959ZOtherBLUE SHIELD ID #1
CAZZZ09960ZOtherBLUE SHIELD ID #2
CAZZZ09959ZOtherBLUE SHIELD ID #1
CADD1613Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CAZZZ28762ZMedicare PIN