Healthcare Provider Details

I. General information

NPI: 1629362140
Provider Name (Legal Business Name): CENTER FOR PAIN RELIEF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 NUTMEG PL STE 103
COSTA MESA CA
92626-2557
US

IV. Provider business mailing address

1520 NUTMEG PL STE 112
COSTA MESA CA
92626-2557
US

V. Phone/Fax

Practice location:
  • Phone: 714-352-3062
  • Fax:
Mailing address:
  • Phone: 714-352-3062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberFNP41445
License Number StateCA

VIII. Authorized Official

Name: DANIEL BONIS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 714-352-3062