Basic Information
| Provider Information | |||||||||
| NPI: | 1235226994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAIN MANAGEMENT JOINT VENTURE, LLP | ||||||||
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| OtherOrganizationName: | CENTRE OF REHABILITATION EXCELLENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3206 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037536635 | ||||||||
| FaxNumber: | 9037531114 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 N MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | LONE STAR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036562419 | ||||||||
| FaxNumber: | 9036562350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALE | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9037536635 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5500600000 | TX | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | TX | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.