1891390118 NPI number — PAIN CARE CENTER LLC

Table of content: (NPI 1891390118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891390118 NPI number — PAIN CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN CARE 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:
1891390118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2620 COMMERCIAL WAY STE 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82901-4705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-212-6270
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
945 W BROADWAY AVE APT 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001-8217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-212-6270
Provider Business Practice Location Address Fax Number:
307-212-6271
Provider Enumeration Date:
12/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RUGER
Authorized Official First Name:
RANDAL
Authorized Official Middle Name:
CHET
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
307-267-2116

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: 132443800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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