Healthcare Provider Details

I. General information

NPI: 1720295249
Provider Name (Legal Business Name): THERAPEUTIC PAIN MANAGEMENT MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 BUENAVENTURA BLVD #100
REDDING CA
96001-0160
US

IV. Provider business mailing address

3116 W MARCH LN STE 200
STOCKTON CA
95219-2369
US

V. Phone/Fax

Practice location:
  • Phone: 530-241-0410
  • Fax: 530-241-0472
Mailing address:
  • Phone: 209-473-6555
  • Fax: 209-473-6543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT HANSEN
Title or Position: MANG PARTNR
Credential: M.D.
Phone: 5302462410410