1639818040 NPI number — PAUSE PAIN AND WELLNESS CENTER LLC

Table of content: (NPI 1639818040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639818040 NPI number — PAUSE PAIN AND WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUSE PAIN AND WELLNESS CENTER 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:
1639818040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 RICKY D BRITT SR BLVD STE 1A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-9111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-940-5060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 RICKY BRITT SR BLVD.
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-212-0685
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GAMMONS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
321-286-7916

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1330513 . This is a "BUSINESS ID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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