1124316724 NPI number — SV PAIN MANAGEMENT PC

Table of content: (NPI 1124316724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124316724 NPI number — SV PAIN MANAGEMENT PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SV PAIN MANAGEMENT PC
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:
1124316724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
171 DWIGHT RD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
LONGMEADOW
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01106-1673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-754-3793
Provider Business Mailing Address Fax Number:
413-754-3467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
171 DWIGHT RD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
LONGMEADOW
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01106-1673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-754-3793
Provider Business Practice Location Address Fax Number:
413-754-3467
Provider Enumeration Date:
07/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MANIKANTAN
Authorized Official First Name:
THENU
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
413-754-3793

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  209825 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com