Provider Demographics
NPI:1689857435
Name:ADVANDCED PAIN MGMT SPECIALIST
Entity Type:Organization
Organization Name:ADVANDCED PAIN MGMT SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-437-8000
Mailing Address - Street 1:3607 OLD CONEJO RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 VISCAYA PKWY
Practice Address - Street 2:#202
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3294
Practice Address - Country:US
Practice Address - Phone:239-437-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92411332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site