Healthcare Provider Details

I. General information

NPI: 1801831631
Provider Name (Legal Business Name): INTERVENTIONAL PAIN SPECIALISTS OF SO CA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7485 MISSION VALLEY RD STE 104B
SAN DIEGO CA
92108-4422
US

IV. Provider business mailing address

PO BOX 969096
SAN DIEGO CA
92196-9096
US

V. Phone/Fax

Practice location:
  • Phone: 619-299-1767
  • Fax: 619-299-0925
Mailing address:
  • Phone: 858-495-0971
  • Fax: 858-495-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: KEVIN SMITH
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 619-299-1767