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General NPI Number Information
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NPI Number | 1497134969
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Entity Type | Organization
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Legal Business Name | CENTRAL VALLEY PAIN MANAGEMENT AND WELLNESS CLINIC INC
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Dates
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Enumeration Date | 05/29/2015
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Last Update Date | 05/29/2015
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Provider Practice Location Address
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Address Line | 1300 MABLE AVE # SUITEB2
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City | MODESTO
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State | CA
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Zip | 95355-1120
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Country | US
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Telephone | 813-448-3848
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Fax |
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Provider Business Mailing Address
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Address Line | 311 PARK PLACE BLVD FL 5
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City | CLEARWATER
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State | FL
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Zip | 33759-4904
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | ARIANA BEDOYA
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Credential |
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Telephone | 813-448-3848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | A51949
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License Number State | CA
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