Healthcare Provider Details

I. General information

NPI: 1124004114
Provider Name (Legal Business Name): SAN DIMAS PAIN MANAGEMENT MEDICAL CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 WHEELER AVE SUITE C
ARCADIA CA
91006-3220
US

IV. Provider business mailing address

125 WHEELER AVE SUITE C
ARCADIA CA
91006-3220
US

V. Phone/Fax

Practice location:
  • Phone: 626-294-4866
  • Fax: 626-294-4872
Mailing address:
  • Phone: 626-294-4866
  • Fax: 626-294-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA53113
License Number StateCA

VIII. Authorized Official

Name: MS. BERNADETTE A CLIFFORD
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 626-294-4866