Provider Demographics
NPI:1710305644
Name:REGIONAL PAIN TREATMENT CENTER
Entity Type:Organization
Organization Name:REGIONAL PAIN TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:CRIS
Authorized Official - Middle Name:MARQUEZ
Authorized Official - Last Name:CANCHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-345-7260
Mailing Address - Street 1:295 IMPERIAL HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1020
Mailing Address - Country:US
Mailing Address - Phone:858-345-7260
Mailing Address - Fax:
Practice Address - Street 1:295 IMPERIAL HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-1020
Practice Address - Country:US
Practice Address - Phone:858-345-7260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59013332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site