Provider Demographics
NPI:1154872083
Name:PAIN CARE CLINIC ACUPUNCTURE
Entity type:Organization
Organization Name:PAIN CARE CLINIC ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:YAN
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:OMD
Authorized Official - Phone:909-997-9966
Mailing Address - Street 1:31740 RAILROAD CANYON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9490
Mailing Address - Country:US
Mailing Address - Phone:909-997-9966
Mailing Address - Fax:951-244-5757
Practice Address - Street 1:31740 RAILROAD CANYON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9490
Practice Address - Country:US
Practice Address - Phone:909-997-9966
Practice Address - Fax:951-244-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-15
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15336171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty