Healthcare Provider Details

I. General information

NPI: 1497193650
Provider Name (Legal Business Name): PENINSULA PAIN RELIEF CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 STATE HIGHWAY 303 NE SUITE A101
BREMERTON WA
98311-3629
US

IV. Provider business mailing address

5050 STATE HIGHWAY 303 NE SUITE A101
BREMERTON WA
98311-3629
US

V. Phone/Fax

Practice location:
  • Phone: 360-478-9788
  • Fax: 360-405-6255
Mailing address:
  • Phone: 360-478-9788
  • Fax: 360-405-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: LARRY MIGGINS
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 360-478-9788