Provider Demographics
NPI:1396896668
Name:TEMECULA PAIN MANAGEMENT CENTER, INC
Entity type:Organization
Organization Name:TEMECULA PAIN MANAGEMENT CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DRUET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-506-9536
Mailing Address - Street 1:43500 RIDGE PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3624
Mailing Address - Country:US
Mailing Address - Phone:951-699-0303
Mailing Address - Fax:951-699-1145
Practice Address - Street 1:25495 MEDICAL CENTER DR
Practice Address - Street 2:STE 102
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4902
Practice Address - Country:US
Practice Address - Phone:951-506-9536
Practice Address - Fax:951-693-4631
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEMECULA PAIN MANAGEMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-15
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA019470261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA019470OtherBUSINESS LCENSE