Provider Demographics
NPI:1720183973
Name:PAIN AND REHABILITATION MEDICAL GROUP, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:PAIN AND REHABILITATION MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PROANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-791-4980
Mailing Address - Street 1:3655 LOMITA BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-1930
Mailing Address - Country:US
Mailing Address - Phone:310-791-4980
Mailing Address - Fax:310-791-4989
Practice Address - Street 1:3655 LOMITA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-1930
Practice Address - Country:US
Practice Address - Phone:310-791-4980
Practice Address - Fax:310-791-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60934207LP2900X
CAG55631207LP2900X
CAPSY46952084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13641Medicare ID - Type Unspecified