Provider Demographics
NPI:1982809646
Name:THE HEAD, NECK, BACK PAIN CENTER
Entity Type:Organization
Organization Name:THE HEAD, NECK, BACK PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-749-7414
Mailing Address - Street 1:10529 SLATER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4841
Mailing Address - Country:US
Mailing Address - Phone:714-965-9999
Mailing Address - Fax:
Practice Address - Street 1:10529 SLATER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4841
Practice Address - Country:US
Practice Address - Phone:714-965-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0228350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU71520Medicare UPIN