Healthcare Provider Details

I. General information

NPI: 1487094058
Provider Name (Legal Business Name): COMPREHENSIVE PAIN CENTER FOR SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 FOUNTAINS BLVD.
MADISON MS
39110
US

IV. Provider business mailing address

129 FOUNTAINS BLVD
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 769-300-0720
  • Fax: 769-300-0721
Mailing address:
  • Phone: 769-300-0720
  • Fax: 769-300-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEONEL K VANCE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 769-300-0720