1548483308 NPI number — COMPREHENSIVE PAIN MANAGEMENT,INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548483308 NPI number — COMPREHENSIVE PAIN MANAGEMENT,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE PAIN MANAGEMENT,INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548483308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 210850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99521-0850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-677-6900
Provider Business Mailing Address Fax Number:
907-677-6999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
851 WESTPOINT DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-7142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-373-7934
Provider Business Practice Location Address Fax Number:
907-373-7935
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACONETTE
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
907-677-7440

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  5328 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MDG171 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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