Provider Demographics
NPI:1689140741
Name:PRISM PAIN AND SPINE, INC
Entity Type:Organization
Organization Name:PRISM PAIN AND SPINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAUCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:661-665-0505
Mailing Address - Street 1:3838 SAN DIMAS, STE.B-231
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301
Mailing Address - Country:US
Mailing Address - Phone:661-665-0505
Mailing Address - Fax:661-665-7844
Practice Address - Street 1:3838 SAN DIMAS, STE.
Practice Address - Street 2:3838 SAN DIMAS,STE. B-231
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301
Practice Address - Country:US
Practice Address - Phone:661-665-0505
Practice Address - Fax:661-665-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty