Basic Information
| Provider Information | |||||||||
| NPI: | 1871540971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAIN MANAGMENT JOINT VENTURE LLP | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRE OF REHABILITATION EXCELLENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3202 N 4TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037536635 | ||||||||
| FaxNumber: | 9032363185 | ||||||||
| Practice Location | |||||||||
| Address1: | 3202 N 4TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037536635 | ||||||||
| FaxNumber: | 9032363185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LORREN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9037536635 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 650460000 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | 5500600000 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 5500600000 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0071BT | 01 | TX | BLUE CROSS | OTHER | 021731701 | 05 | TX | MEDICAID |