Healthcare Provider Details

I. General information

NPI: 1871657403
Provider Name (Legal Business Name): CENTRAL VALLEY PAIN MANAGEMENT AND WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MABLE AVENUE SUITE 2
MODESTO CA
95355-1120
US

IV. Provider business mailing address

1300 MABLE AVENUE 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 TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number00A519490
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number00A519490
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number00A519490
License Number StateCA

VIII. Authorized Official

Name: PATRICK NEAL RHOADES
Title or Position: PRESIDENT
Credential: MD
Phone: 209-571-1992