Provider Demographics
NPI:1871936450
Name:ADVANCED PAIN MANAGEMENT & WELLNESS, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT & WELLNESS, A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:213-413-0413
Mailing Address - Street 1:1930 WILSHIRE BLVD
Mailing Address - Street 2:804
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3605
Mailing Address - Country:US
Mailing Address - Phone:213-413-0413
Mailing Address - Fax:213-947-4075
Practice Address - Street 1:1930 WILSHIRE BLVD
Practice Address - Street 2:804
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3605
Practice Address - Country:US
Practice Address - Phone:213-413-0413
Practice Address - Fax:213-947-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG075155174400000X
261QP3300X
MDPA52058261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty