Provider Demographics
NPI:1053568030
Name:ADVANCED INTERVENTIONAL PAIN AND WELLNESS CENTER INC
Entity type:Organization
Organization Name:ADVANCED INTERVENTIONAL PAIN AND WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:GILBERT
Authorized Official - Last Name:DING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-444-1886
Mailing Address - Street 1:218 AVENIDA LA CUESTA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2139
Mailing Address - Country:US
Mailing Address - Phone:949-444-1885
Mailing Address - Fax:888-873-6807
Practice Address - Street 1:6700 INDIANA AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4290
Practice Address - Country:US
Practice Address - Phone:951-248-9240
Practice Address - Fax:951-248-9263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
CAA66008261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
G77154Medicare UPIN
BH362Medicare PIN
CA7567570001Medicare NSC
POO688811Medicare PIN