Healthcare Provider Details

I. General information

NPI: 1063217438
Provider Name (Legal Business Name): PAIN TREATMENT CENTERS OF AMERICA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 MALCOLM AVE STE B
NEWPORT AR
72112-3697
US

IV. Provider business mailing address

PO BOX 23120
LITTLE ROCK AR
72221-3120
US

V. Phone/Fax

Practice location:
  • Phone: 844-215-0731
  • Fax: 888-630-8885
Mailing address:
  • Phone: 501-900-8770
  • Fax: 210-526-3087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LISA KENT
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 501-900-8770