=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780689802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN DIAGNOSTIC AND TREATMENT CENTER LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 11/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2805 J. ST STE 200
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-462-9800
-----------------------------------------------------
Fax | 916-462-9801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2805 J. ST STE 200
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-4307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-462-9800
-----------------------------------------------------
Fax | 916-462-9801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER, AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | ERIC BOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-567-0269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 030000705
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------