1790221612 NPI number — INTERVENTIONAL PAIN CENTER, PLLC

Table of content: (NPI 1790221612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790221612 NPI number — INTERVENTIONAL PAIN CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN CENTER, PLLC
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:
1790221612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2153 VALLEYGATE DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-3681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-321-7246
Provider Business Mailing Address Fax Number:
910-321-7245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 RUIN CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27536-2878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-438-3186
Provider Business Practice Location Address Fax Number:
252-438-2602
Provider Enumeration Date:
01/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DESAI
Authorized Official First Name:
VIREN
Authorized Official Middle Name:
DINKERRAI
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
910-321-7246

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  200100673 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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