Healthcare Provider Details

I. General information

NPI: 1265565162
Provider Name (Legal Business Name): CENTRAL VALLEY PAIN MANAGEMENT & WELLNESS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MABLE AVE SUITE 2
MODESTO CA
95355-1120
US

IV. Provider business mailing address

1300 MABLE AVE SUITE 2
MODESTO CA
95355-1120
US

V. Phone/Fax

Practice location:
  • Phone: 209-571-1992
  • Fax: 209-571-1994
Mailing address:
  • Phone: 209-571-1992
  • Fax: 209-571-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberPA13793
License Number StateCA

VIII. Authorized Official

Name: MRS. KRISTY LINDSTROM
Title or Position: SPA DIRECTOR
Credential: P.A.
Phone: 209-571-1992