Healthcare Provider Details

I. General information

NPI: 1265784862
Provider Name (Legal Business Name): INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 CONNECTICUT AVE S
SARTELL MN
56377-2474
US

IV. Provider business mailing address

2301 CONNECTICUT AVE S
SARTELL MN
56377-2474
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-1500
  • Fax: 320-229-1505
Mailing address:
  • Phone: 320-229-1500
  • Fax: 320-229-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MRS. STACY KOWALKOWSKI
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 320-229-1500