Healthcare Provider Details

I. General information

NPI: 1972030062
Provider Name (Legal Business Name): LAFAYETTE PAIN CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 TERRACE DR
WINAMAC IN
46996-1111
US

IV. Provider business mailing address

770 PARK EAST BLVD SUITE B
LAFAYETTE IN
47905-0786
US

V. Phone/Fax

Practice location:
  • Phone: 574-946-4290
  • Fax: 574-946-6678
Mailing address:
  • Phone: 765-714-4344
  • Fax: 765-838-3200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHAZIA M SIDDIQUI
Title or Position: OWNER
Credential: MD
Phone: 765-714-4344