1871985788 NPI number — PAIN MANAGEMENT RESOURCES INC

Table of content: MARSHA BOSSEAU RN (NPI 1497467435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871985788 NPI number — PAIN MANAGEMENT RESOURCES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT RESOURCES 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:
1871985788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30233
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73003-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-285-8506
Provider Business Mailing Address Fax Number:
888-680-6040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 NAVARRE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43616-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-285-8506
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ABOU-CHAKRA
Authorized Official First Name:
IMAN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-285-8506

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  35083590 , 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: H448300 . This is a "GROUP MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0019551 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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