1740582303 NPI number — PAIN CENTER INC

Table of content: (NPI 1740582303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740582303 NPI number — PAIN CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN CENTER INC
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:
1740582303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
633 N 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83702-4510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-342-9800
Provider Business Mailing Address Fax Number:
208-342-4223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 N 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-4510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-9800
Provider Business Practice Location Address Fax Number:
208-342-4223
Provider Enumeration Date:
12/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-342-9800

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP3300X , with the licence number: M5883 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004277900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com