1285902403 NPI number — PAIN AND SPINE CENTER OF THE DESERT INC.

Table of content: (NPI 1336306620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285902403 NPI number — PAIN AND SPINE CENTER OF THE DESERT INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN AND SPINE CENTER OF THE DESERT INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285902403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6720
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA QUINTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92248-6720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-776-7999
Provider Business Mailing Address Fax Number:
760-776-7994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
73271 FRED WARING DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-2883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-776-7999
Provider Business Practice Location Address Fax Number:
760-776-7994
Provider Enumeration Date:
12/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOUFFARD
Authorized Official First Name:
MARK
Authorized Official Middle Name:
HENRY CORONEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-776-7999

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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