1558666149 NPI number — PAINSTOP SPINE CLINIC, LLC

Table of content: (NPI 1558666149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558666149 NPI number — PAINSTOP SPINE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAINSTOP SPINE CLINIC, 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:
1558666149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4594
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILOXI
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39535-4594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-273-4096
Provider Business Mailing Address Fax Number:
228-594-1765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 SHORTCUT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCAGOULA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39567-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-273-4096
Provider Business Practice Location Address Fax Number:
228-594-1765
Provider Enumeration Date:
01/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TSANG
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
626-512-6348

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00057070 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30270G0134 . This is a "MCR PTAN GROUP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: DT9919 . This is a "RAILROAD MEDICARE, GROUP PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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