Provider Demographics
NPI:1285902403
Name:PAIN AND SPINE CENTER OF THE DESERT INC.
Entity type:Organization
Organization Name:PAIN AND SPINE CENTER OF THE DESERT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:HENRY CORONEL
Authorized Official - Last Name:BOUFFARD
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:760-776-7999
Mailing Address - Street 1:PO BOX 6720
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92248-6720
Mailing Address - Country:US
Mailing Address - Phone:760-776-7999
Mailing Address - Fax:760-776-7994
Practice Address - Street 1:73271 FRED WARING DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2883
Practice Address - Country:US
Practice Address - Phone:760-776-7999
Practice Address - Fax:760-776-7994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain