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General NPI Number Information
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NPI Number | 1912376005
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Entity Type | Organization
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Legal Business Name | PENINSULA PAIN CLINIC, PLLC
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Dates
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Enumeration Date | 09/18/2015
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Last Update Date | 07/22/2019
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Provider Practice Location Address
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Address Line | 2601 CHERRY AVE STE 200
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City | BREMERTON
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State | WA
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Zip | 98310-4208
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Country | US
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Telephone | 360-415-9110
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Fax | 360-479-0265
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Provider Business Mailing Address
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Address Line | 2980 N BEVERLY GLEN CIR STE 100
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City | LOS ANGELES
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State | CA
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Zip | 90077-1728
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Country | US
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Telephone | 310-943-4180
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Fax | 888-431-8819
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | TERRY PEXTON
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Credential | DO
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Telephone | 360-415-9110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | OP60339103
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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