Healthcare Provider Details

I. General information

NPI: 1205911716
Provider Name (Legal Business Name): INTERVENTIONAL PAIN CENTER OF MERCED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 E YOSEMITE AVE STE C
MERCED CA
95340-8221
US

IV. Provider business mailing address

1390 E YOSEMITE AVE STE C
MERCED CA
95340-8221
US

V. Phone/Fax

Practice location:
  • Phone: 209-724-0316
  • Fax: 209-724-0318
Mailing address:
  • Phone: 209-724-0316
  • Fax: 209-724-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number550000054
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number550000054
License Number StateCA

VIII. Authorized Official

Name: DR. RAMAKRISHNA R THONDAPU
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 209-724-0316