Healthcare Provider Details

I. General information

NPI: 1922469865
Provider Name (Legal Business Name): CHOICE PAIN & REBABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5102 CORNELIAS PROSPECT DR
BOWIE MD
20720-3375
US

IV. Provider business mailing address

5102 CORNELIAS PROSPECT DR
BOWIE MD
20720-3375
US

V. Phone/Fax

Practice location:
  • Phone: 240-786-1001
  • Fax:
Mailing address:
  • Phone: 240-786-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberD0068884
License Number StateMD

VIII. Authorized Official

Name: TRISTAN SHOCKLEY
Title or Position: OWNER
Credential:
Phone: 240-786-1001