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General NPI Number Information
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NPI Number | 1043559081
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Entity Type | Organization
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Legal Business Name | YAKIMA RIVER PAIN MANAGEMENT PS
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Dates
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Enumeration Date | 02/12/2013
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Last Update Date | 03/15/2013
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Provider Practice Location Address
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Address Line | 109 S WATER ST SUITE 2
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City | ELLENSBURG
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State | WA
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Zip | 98926-3061
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Country | US
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Telephone | 509-962-2273
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Fax | 509-962-2270
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Provider Business Mailing Address
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Address Line | 109 S WATER ST SUITE 2
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City | ELLENSBURG
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State | WA
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Zip | 98926-3061
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Country | US
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Telephone | 509-962-2273
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Fax | 509-962-2270
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MR. GARY L FAVERO
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Credential |
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Telephone | 509-962-2273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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