=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588113062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN CARE PHYSICIANS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2016
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1628 S MILDRED ST STE 102
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98465-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-538-6300
-----------------------------------------------------
Fax | 206-538-6301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 SW 16TH ST STE. 121
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98057-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-538-6300
-----------------------------------------------------
Fax | 206-538-6301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REVENUE AND FINANCE
-----------------------------------------------------
Name | KEVIN MOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-538-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 604032151
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 604032151
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------