Provider Demographics
NPI:1689611568
Name:LODI PAIN CLINIC, INC.
Entity Type:Organization
Organization Name:LODI PAIN CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARMANJEET
Authorized Official - Middle Name:C
Authorized Official - Last Name:DHALIWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-339-0300
Mailing Address - Street 1:PO BOX 34120
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-4120
Mailing Address - Country:US
Mailing Address - Phone:775-747-5050
Mailing Address - Fax:775-747-5005
Practice Address - Street 1:777 S HAM LN
Practice Address - Street 2:SUITE F
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3591
Practice Address - Country:US
Practice Address - Phone:209-339-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03849ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER