Provider Demographics
NPI:1013046705
Name:SOFT TISSUE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SOFT TISSUE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:831-373-0188
Mailing Address - Street 1:648 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-3347
Mailing Address - Country:US
Mailing Address - Phone:831-373-0188
Mailing Address - Fax:831-373-6979
Practice Address - Street 1:648 PINE AVE
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-3347
Practice Address - Country:US
Practice Address - Phone:831-373-0188
Practice Address - Fax:831-373-6979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19245111NR0400X
CAG42005208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0192450OtherDAP - BS
CA00G420050OtherRWT - BS
CA1619998960OtherRWT NPI
CADC19245OtherDAP - BC
CAG42005OtherRWT - BC
CAZZZ66746ZOtherBLUE SHIELD
CA1134258825OtherDAP - NPI
CA=========OtherTIN
CAZZZ03481ZMedicare ID - Type Unspecified
CA=========OtherTIN
CADC19245OtherDAP - BC