Healthcare Provider Details

I. General information

NPI: 1619513157
Provider Name (Legal Business Name): PREMIER PAIN CARE & WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CROSS ST STE 301
NORWALK CT
06851-4647
US

IV. Provider business mailing address

40 CROSS ST STE 301
NORWALK CT
06851-4647
US

V. Phone/Fax

Practice location:
  • Phone: 203-956-0022
  • Fax: 203-956-0024
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GENDAI ECHEZONA
Title or Position: PROVIDER
Credential: MD
Phone: 914-469-7877