Basic Information
| Provider Information | |||||||||
| NPI: | 1629409578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN CENTER OF WYOMING VALLEY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1177 HIGHWAY 315 BLVD | ||||||||
| Address2: | DOLPHIN PLAZA | ||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187026928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702705712 | ||||||||
| FaxNumber: | 5702705719 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 MUNDY ST | ||||||||
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| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187026875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702705712 | ||||||||
| FaxNumber: | 5702705719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2013 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | PAZ | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5702705712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 23881501 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1030398800001 | 05 | PA | MEDICAID |