1821217654 NPI number — JOPLIN DISC AND PAIN SOLUTIONS

Table of content: (NPI 1821217654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821217654 NPI number — JOPLIN DISC AND PAIN SOLUTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOPLIN DISC AND PAIN SOLUTIONS
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:
RENUVA BACK AND PAIN CENTERS
Provider Other Organization Name Type Code:
5
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:
1821217654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2302 E 32ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64804-4301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-781-3472
Provider Business Mailing Address Fax Number:
417-781-1774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2302 E 32ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-4301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-781-3472
Provider Business Practice Location Address Fax Number:
417-781-1774
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RILEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-781-3472

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  01-4728 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 2010010250 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1700998721 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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