Provider Demographics
NPI:1952857823
Name:PACIFIC REGENERATIVE AND INTERVENTIONAL SPORTS MEDICINE
Entity Type:Organization
Organization Name:PACIFIC REGENERATIVE AND INTERVENTIONAL SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BLATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:408-440-0930
Mailing Address - Street 1:6080 HELLYER AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-1052
Mailing Address - Country:US
Mailing Address - Phone:408-440-0930
Mailing Address - Fax:408-440-0389
Practice Address - Street 1:6080 HELLYER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138-1052
Practice Address - Country:US
Practice Address - Phone:408-440-0930
Practice Address - Fax:408-440-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124037261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty