Healthcare Provider Details

I. General information

NPI: 1962774745
Provider Name (Legal Business Name): PAIN, INJURY & BRAIN CENTERS OF AMERICA MN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14247 OCONNELL CT
SAVAGE MN
55378-2878
US

IV. Provider business mailing address

17838 25TH ST SE
DOVER MN
55929-1500
US

V. Phone/Fax

Practice location:
  • Phone: 507-269-1051
  • Fax:
Mailing address:
  • Phone: 507-269-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. SUE HENRY
Title or Position: OWNER
Credential:
Phone: 507-269-1051