Provider Demographics
NPI:1720295249
Name:THERAPEUTIC PAIN MANAGEMENT MEDICAL CLINIC
Entity type:Organization
Organization Name:THERAPEUTIC PAIN MANAGEMENT MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANG PARTNR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530246-241-0410
Mailing Address - Street 1:3116 W MARCH LN
Mailing Address - Street 2:STE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2369
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6543
Practice Address - Street 1:1335 BUENAVENTURA BLVD
Practice Address - Street 2:#100
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0160
Practice Address - Country:US
Practice Address - Phone:530-241-0410
Practice Address - Fax:530-241-0472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA043275OtherDE. DHRUVA'S MD LIC #
CAPENDINGMedicaid
CAG047619OtherDR HANSEN MD LIC #
CAA070414OtherDR IRANPUR MD LIC #
CAPENDINGMedicaid