Basic Information
| Provider Information | |||||||||
| NPI: | 1326237298 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN TREATMENT CENTERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 849 | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370700849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153521212 | ||||||||
| FaxNumber: | 6153521215 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 WHITE BRIDGE RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372051499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153521212 | ||||||||
| FaxNumber: | 6153521215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | CYRUS | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6153521212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 33285902 | 05 | TN | MEDICAID |