MEDICARE: PAIN, INJURY & BRAIN CENTERS OF AMERICA MN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1962774745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN, INJURY & BRAIN CENTERS OF AMERICA MN LLC

Provider Business Mailing Address
First Line	:	17838 25TH ST SE
Second Line	:
City	:	DOVER
State	:	MN
Zip	:	55929-1500
Country	:	US
Telephone Number	:	507-269-1051
Fax Number	:

Provider Business Practice Location Address
First Line	:	14247 OCONNELL CT
Second Line	:
City	:	SAVAGE
State	:	MN
Zip	:	55378-2878
Country	:	US
Telephone Number	:	507-269-1051
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SUE HENRY
Credential	:
Telephone Number	:	507-269-1051

Provider Enumeration Date	:	02/08/2012
Last Update Date	:	02/08/2012

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