Healthcare Provider Details

I. General information

NPI: 1730240854
Provider Name (Legal Business Name): PAIN MANAGEMENT CENTER OF FARMINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 FARMINGTON AVE
FARMINGTON CT
06032-1909
US

IV. Provider business mailing address

270 FARMINGTON AVE SUITE 337
FARMINGTON CT
06032-1909
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-6671
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRUCE GOTTLIEB
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 860-677-6671