Healthcare Provider Details

I. General information

NPI: 1851628333
Provider Name (Legal Business Name): MT BAKER PAIN CLINIC, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4029 NORTHWEST AVE STE 301
BELLINGHAM WA
98226-9077
US

IV. Provider business mailing address

4029 NORTHWEST AVE STE 301
BELLINGHAM WA
98226-9077
US

V. Phone/Fax

Practice location:
  • Phone: 360-752-0518
  • Fax: 360-676-2896
Mailing address:
  • Phone: 360-752-0518
  • Fax: 360-676-2896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number602939596
License Number StateWA

VIII. Authorized Official

Name: JENNIFER CERAR
Title or Position: CLINICAL MANAGER
Credential: RN, CRRN, CASC
Phone: 360-752-0518