Provider Demographics
NPI:1073409488
Name:KENNEWICK PAIN CLINIC INC PS
Entity type:Organization
Organization Name:KENNEWICK PAIN CLINIC INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DNP
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:941-224-1025
Mailing Address - Street 1:710 W MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:RITZVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99169-1833
Mailing Address - Country:US
Mailing Address - Phone:941-224-1025
Mailing Address - Fax:
Practice Address - Street 1:835 E COLONIAL AVE STE 102
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4617
Practice Address - Country:US
Practice Address - Phone:941-224-1025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty