Provider Demographics
NPI:1871657403
Name:CENTRAL VALLEY PAIN MANAGEMENT AND WELLNESS CLINIC
Entity Type:Organization
Organization Name:CENTRAL VALLEY PAIN MANAGEMENT AND WELLNESS CLINIC
Other - Org Name:CENTRAL VALLEY PAIN MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:RHOADES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-571-1992
Mailing Address - Street 1:1300 MABLE AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1120
Mailing Address - Country:US
Mailing Address - Phone:209-571-1992
Mailing Address - Fax:209-571-1994
Practice Address - Street 1:1300 MABLE AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1120
Practice Address - Country:US
Practice Address - Phone:209-571-1992
Practice Address - Fax:209-571-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A519490204C00000X, 2081P2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A519490Medicaid
CA00A519490Medicaid