Healthcare Provider Details

I. General information

NPI: 1518020999
Provider Name (Legal Business Name): PAIN TREATMENT CENTER OF LAUREL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 S 13TH AVE
LAUREL MS
39440-4345
US

IV. Provider business mailing address

404 S 13TH AVE
LAUREL MS
39440-4345
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-9042
  • Fax:
Mailing address:
  • Phone: 601-425-9042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID L MCKELLAR
Title or Position: OWNER
Credential: M.D.
Phone: 601-268-8698