MEDICARE: CORPUS CHRISTI PAIN MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center	L9326	TX

General Provider Information

NPI Number	:	1073913976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORPUS CHRISTI PAIN MEDICINE

Provider Business Mailing Address
First Line	:	4833 SARATOGA BLVD # 272
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78413-2213
Country	:	US
Telephone Number	:	361-225-0089
Fax Number	:	361-225-0082

Provider Business Practice Location Address
First Line	:	3825 S PADRE ISLAND DR
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78415-2913
Country	:	US
Telephone Number	:	361-225-0089
Fax Number	:	361-225-0082

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LAURA LOPEZ
Credential	:
Telephone Number	:	361-225-0089

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	08/27/2014

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