Healthcare Provider Details

I. General information

NPI: 1053690404
Provider Name (Legal Business Name): PAIN MANAGEMENT PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 SUNSET OFFICE DR SUITE C110
SAINT LOUIS MO
63127-1015
US

IV. Provider business mailing address

PO BOX 798348
SAINT LOUIS MO
63179-8000
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-8778
  • Fax: 314-909-8777
Mailing address:
  • Phone: 314-275-8737
  • Fax: 314-205-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CANDACE MANGRUM
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-275-8737