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General NPI Number Information
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NPI Number | 1811992068
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Entity Type | Organization
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Legal Business Name | COMMUNITY PAIN MANAGEMENT MEDICAL CLINIC INC
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Dates
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Enumeration Date | 06/15/2005
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 4500 BROCKTON AVE STE 305
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City | RIVERSIDE
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State | CA
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Zip | 92501-4028
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Country | US
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Telephone | 951-715-3963
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Fax | 951-715-3960
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Provider Business Mailing Address
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Address Line | PO BOX 1509
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City | RIVERSIDE
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State | CA
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Zip | 92502-1509
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Country | US
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Telephone | 951-715-3963
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Fax | 951-715-3960
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JAN PAUL MADDOX
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Credential | M.D.,FIPP,ABA,ABPM
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Telephone | 951-715-3963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | A32046
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License Number State | CA
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