Healthcare Provider Details

I. General information

NPI: 1992888994
Provider Name (Legal Business Name): INTERDISCIPLANARY PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 AUTO CENTER DRIVE
PALMDALE CA
93551
US

IV. Provider business mailing address

819 AUTO CENTER DRIVE
PALMDALE CA
93551
US

V. Phone/Fax

Practice location:
  • Phone: 661-267-6876
  • Fax: 661-538-9438
Mailing address:
  • Phone: 661-267-6876
  • Fax: 661-538-9438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: MR. LANCE JACKSON
Title or Position: CEO
Credential: DC
Phone: 661-267-6876