Provider Demographics
NPI:1891819447
Name:PAIN DIAGNOSIS & TREATMENT, INC. A MEDICAL CLINIC
Entity Type:Organization
Organization Name:PAIN DIAGNOSIS & TREATMENT, INC. A MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:GWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-857-7400
Mailing Address - Street 1:210 S GRAND AVE
Mailing Address - Street 2:315
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4205
Mailing Address - Country:US
Mailing Address - Phone:626-857-7400
Mailing Address - Fax:626-857-7404
Practice Address - Street 1:210 S GRAND AVE
Practice Address - Street 2:315
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4205
Practice Address - Country:US
Practice Address - Phone:626-857-7400
Practice Address - Fax:626-857-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43746207LP2900X
CAA20970207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A437461Medicaid
CAE01555Medicare UPIN
CA00A437461Medicaid
CAA09730Medicare UPIN
CAWA20970EMedicare ID - Type UnspecifiedJOHN RITTER, MD-GLENDORA
CAE01555Medicare UPIN
CAWA43746KMedicare ID - Type UnspecifiedBRIAN GWARTZ, MD-GLENDORA