Provider Demographics
NPI:1841683984
Name:PAIN RECOVERY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:PAIN RECOVERY MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-308-0461
Mailing Address - Street 1:PO BOX 6747
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-6747
Mailing Address - Country:US
Mailing Address - Phone:714-377-3749
Mailing Address - Fax:714-377-5642
Practice Address - Street 1:34085 PACIFIC COAST HWY
Practice Address - Street 2:#203
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2764
Practice Address - Country:US
Practice Address - Phone:714-377-3749
Practice Address - Fax:714-377-5642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder