Provider Demographics
NPI:1730324518
Name:STOCKTON PAIN MEDICAL CENTER
Entity Type:Organization
Organization Name:STOCKTON PAIN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:NMI
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-951-5960
Mailing Address - Street 1:3031 W MARCH LANE
Mailing Address - Street 2:#101
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:209-951-5960
Mailing Address - Fax:209-951-5967
Practice Address - Street 1:3031 W MARCH LANE
Practice Address - Street 2:#101
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219
Practice Address - Country:US
Practice Address - Phone:209-951-5960
Practice Address - Fax:209-951-5967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D1086032291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1086012Medicaid