Basic Information
| Provider Information | |||||||||
| NPI: | 1801123328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRGINIA PAIN & SPINE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5372 FALLOWATER LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240180907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407257364 | ||||||||
| FaxNumber: | 5407257368 | ||||||||
| Practice Location | |||||||||
| Address1: | 5372 FALLOWATER LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240180907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407257364 | ||||||||
| FaxNumber: | 5407257368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | UNG | ||||||||
| AuthorizedOfficialFirstName: | CHHEANY | ||||||||
| AuthorizedOfficialMiddleName: | WALTER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7174182141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | 0101242119 | VA | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.