Basic Information
| Provider Information | |||||||||
| NPI: | 1144756768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAIN CENTER OF VIRGINIA, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PAIN CENTER OF WEST VIRGINIA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 TAVERN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042636165 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1839 WEST PLAZA DRIVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407732689 | ||||||||
| FaxNumber: | 5404864166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2017 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARRICK | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3042636165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 25285 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.