Healthcare Provider Details

I. General information

NPI: 1912287038
Provider Name (Legal Business Name): PAIN INJURY AND BRAIN CENTERS OF AMERICA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2011
Last Update Date: 08/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4465 HIGHWAY 61
GOODVIEW MN
55987-1659
US

IV. Provider business mailing address

4465 HIGHWAY 61
GOODVIEW MN
55987-1659
US

V. Phone/Fax

Practice location:
  • Phone: 507-410-1144
  • Fax: 507-410-1144
Mailing address:
  • Phone: 507-410-1144
  • Fax: 507-410-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR134470-7
License Number StateMN

VIII. Authorized Official

Name: HAL KENNER
Title or Position: CLINICIAN
Credential: CRNA
Phone: 507-410-1144