Basic Information
| Provider Information | |||||||||
| NPI: | 1609257773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE PAIN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 E PRIMROSE ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175531080 | ||||||||
| FaxNumber: | 8884725145 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 E PRIMROSE ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175531080 | ||||||||
| FaxNumber: | 8884725145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | TONKIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 4177204991 | ||||||||
| 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 | 332B00000X | MO | N | Suppliers | Durable Medical Equipment & Medical Supplies | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2007017247 | 01 | MO | MISSOURI MEDICAL LICENSE | OTHER | 7422650001 | 01 | MO | NATIONAL SUPPLIER CLEARING HOUSE MEDICARE DMEPOS | OTHER | FT3614307 | 01 | MO | MISSOURI DEA LICENSE | OTHER |