Provider Demographics
NPI:1780689802
Name:PAIN DIAGNOSTIC AND TREATMENT CENTER LP
Entity Type:Organization
Organization Name:PAIN DIAGNOSTIC AND TREATMENT CENTER LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:2805 J. ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4307
Mailing Address - Country:US
Mailing Address - Phone:916-462-9800
Mailing Address - Fax:916-462-9801
Practice Address - Street 1:2805 J. ST
Practice Address - Street 2:STE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4307
Practice Address - Country:US
Practice Address - Phone:916-462-9800
Practice Address - Fax:916-462-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000705261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA490004875OtherRAILROAD MEDICARE
CA0153037OtherSTATE OF WA DEPT OF LABOR
CA184315700OtherUS DEPT OF LABOR
CASUR01481FMedicaid
CAZZZH3417AOtherBLUE SHIELD OF CA
CA184315700OtherUS DEPT OF LABOR
CASUR01481FMedicaid