Healthcare Provider Details

I. General information

NPI: 1912297599
Provider Name (Legal Business Name): INTERVENTIONAL PAIN TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 S 1ST ST LOUISVILLE SURGERY CENTER
LOUISVILLE KY
40202-1474
US

IV. Provider business mailing address

444 S 1ST ST LOUISVILLE SURGERY CENTER
LOUISVILLE KY
40202-1474
US

V. Phone/Fax

Practice location:
  • Phone: 502-238-2896
  • Fax:
Mailing address:
  • Phone: 502-238-2896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number20434
License Number StateKY

VIII. Authorized Official

Name: MR. ELMER E DUNBAR
Title or Position: OWNER
Credential: MD
Phone: 502-238-2896