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General NPI Number Information
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NPI Number | 1154766566
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Entity Type | Organization
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Legal Business Name | 5 STAR PAIN RELIEF PC
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Dates
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Enumeration Date | 04/30/2013
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Last Update Date | 05/14/2015
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Provider Practice Location Address
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Address Line | 44530 SAN PABLO AVE SUITE 204
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City | PALM DESERT
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State | CA
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Zip | 92260-3596
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Country | US
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Telephone | 760-340-1264
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Fax | 760-340-0382
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Provider Business Mailing Address
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Address Line | 44530 SAN PABLO AVE SUITE 204
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City | PALM DESERT
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State | CA
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Zip | 92260-3596
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Country | US
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Telephone | 760-340-1264
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Fax | 760-340-0982
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Authorized Official
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Title or Position | PRESIDENT
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Name | WILLIAM LEE HATHAWAY
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Credential | DC
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Telephone | 760-340-1264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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