Provider Demographics
NPI:1265435416
Name:PAIN MANAGEMENT SPECIALISTS MEDICAL GROUP
Entity type:Organization
Organization Name:PAIN MANAGEMENT SPECIALISTS MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:INNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIBANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-782-8132
Mailing Address - Street 1:PO BOX 4659
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-4659
Mailing Address - Country:US
Mailing Address - Phone:805-782-8132
Mailing Address - Fax:805-597-8350
Practice Address - Street 1:10 SANTA ROSA ST
Practice Address - Street 2:STE 201
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5825
Practice Address - Country:US
Practice Address - Phone:805-782-8132
Practice Address - Fax:805-597-8350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0105740Medicaid
CAGR0105740Medicaid