1609269653 NPI number — PM&R PAIN FREE, LLC

Table of content: (NPI 1609269653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609269653 NPI number — PM&R PAIN FREE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM&R PAIN FREE, 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:
6
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:
1609269653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19645 PROGRESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRONGSVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44149-3205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-234-8833
Provider Business Mailing Address Fax Number:
440-234-3313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 ALKYRE RUN STE 360
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43082-6914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-918-9808
Provider Business Practice Location Address Fax Number:
614-918-9807
Provider Enumeration Date:
03/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GOULD
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
614-918-9808

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  34009895 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0121242 GROUP , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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