1902159809 NPI number — ADVANCED PAIN CARE, PC

Table of content: (NPI 1902159809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902159809 NPI number — ADVANCED PAIN CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PAIN CARE, PC
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:
1902159809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
638 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-1887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-482-1712
Provider Business Mailing Address Fax Number:
541-482-1777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
638 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-1887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-482-1712
Provider Business Practice Location Address Fax Number:
541-482-1777
Provider Enumeration Date:
10/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WERNER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
541-482-1712

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD18140 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R110996 . This is a "PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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