Provider Demographics
NPI:1427046655
Name:UNIVERSAL PAIN MANAGEMENT MEDICAL CORPORATION
Entity type:Organization
Organization Name:UNIVERSAL PAIN MANAGEMENT MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING / CREDENTIALING
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-267-6878
Mailing Address - Street 1:819 AUTO CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4599
Mailing Address - Country:US
Mailing Address - Phone:661-267-6878
Mailing Address - Fax:661-267-0438
Practice Address - Street 1:819 AUTO CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4599
Practice Address - Country:US
Practice Address - Phone:661-267-6876
Practice Address - Fax:661-538-9438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6468310001Medicare NSC
CAW15352Medicare UPIN