1700849247 NPI number — PAIN MANAGEMENT INTERVENTIONS, LLC

Table of content: (NPI 1700849247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700849247 NPI number — PAIN MANAGEMENT INTERVENTIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT INTERVENTIONS, 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:
1700849247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63902-0393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-785-4601
Provider Business Mailing Address Fax Number:
573-776-6127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 ROOSEVELT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-983-8300
Provider Business Practice Location Address Fax Number:
573-776-6127
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SOETER
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-983-8300

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 505222703 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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