Healthcare Provider Details

I. General information

NPI: 1336408186
Provider Name (Legal Business Name): PREMIER PAIN CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514F E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

IV. Provider business mailing address

514F E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-3132
  • Fax: 601-982-3136
Mailing address:
  • Phone: 601-982-3132
  • Fax: 601-982-3136

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: DR. LORI MARSHALL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-982-3132