1609257773 NPI number — ELITE PAIN MANAGEMENT, LLC

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 1609257773 NPI number — ELITE PAIN MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE PAIN MANAGEMENT, LLC
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:
1609257773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 E KINGSLEY ST STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-7231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-553-1080
Provider Business Mailing Address Fax Number:
888-472-5145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 E KINGSLEY ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-7231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-553-1080
Provider Business Practice Location Address Fax Number:
888-472-5145
Provider Enumeration Date:
06/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TONKIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
417-720-4991

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2007017247 . This is a "MISSOURI MEDICAL LICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7422650001 . This is a "NATIONAL SUPPLIER CLEARING HOUSE MEDICARE DMEPOS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com