Healthcare Provider Details

I. General information

NPI: 1811992068
Provider Name (Legal Business Name): COMMUNITY PAIN MANAGEMENT MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE STE 305
RIVERSIDE CA
92501-4028
US

IV. Provider business mailing address

PO BOX 1509
RIVERSIDE CA
92502-1509
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-3963
  • Fax: 951-715-3960
Mailing address:
  • Phone: 951-715-3963
  • Fax: 951-715-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA32046
License Number StateCA

VIII. Authorized Official

Name: DR. JAN PAUL MADDOX
Title or Position: MEDICAL DIRECTOR
Credential: M.D.,FIPP,ABA,ABPM
Phone: 951-715-3963