Healthcare Provider Details

I. General information

NPI: 1104864909
Provider Name (Legal Business Name): PAIN CLINIC OF MONTEREY BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SOQUEL DRIVE
SANTA CRUZ CA
95065
US

IV. Provider business mailing address

55 PENNY LANE STE 103
WATSONVILLE CA
95076
US

V. Phone/Fax

Practice location:
  • Phone: 831-462-7700
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. LAWRENCE POREE
Title or Position: PRESIDENT
Credential: MD
Phone: 831-724-6111