Healthcare Provider Details

I. General information

NPI: 1013046705
Provider Name (Legal Business Name): SOFT TISSUE MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 PINE AVE
PACIFIC GROVE CA
93950-3347
US

IV. Provider business mailing address

648 PINE AVE
PACIFIC GROVE CA
93950-3347
US

V. Phone/Fax

Practice location:
  • Phone: 831-373-0188
  • Fax: 831-373-6979
Mailing address:
  • Phone: 831-373-0188
  • Fax: 831-373-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC19245
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG42005
License Number StateCA

VIII. Authorized Official

Name: DR. ANTHONY MICHAEL PAYAN
Title or Position: OWNER/OFFICER
Credential: DC
Phone: 831-373-0188