Healthcare Provider Details

I. General information

NPI: 1457521189
Provider Name (Legal Business Name): PAIN RELIEF ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SPRING DR
SAINT CHARLES MO
63303-3255
US

IV. Provider business mailing address

PO BOX 790126 DEPT 10203
SAINT LOUIS MO
63179-0126
US

V. Phone/Fax

Practice location:
  • Phone: 636-946-0799
  • Fax: 636-946-3166
Mailing address:
  • Phone: 636-600-1137
  • Fax: 636-600-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW J WISE
Title or Position: MANAGING MEMBER
Credential:
Phone: 636-946-0799