Healthcare Provider Details

I. General information

NPI: 1790221612
Provider Name (Legal Business Name): INTERVENTIONAL PAIN CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 RUIN CREEK RD SUITE 103
HENDERSON NC
27536-2878
US

IV. Provider business mailing address

PO BOX 931038
ATLANTA GA
31193-1038
US

V. Phone/Fax

Practice location:
  • Phone: 252-438-3186
  • Fax: 252-438-2602
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number200100673
License Number StateNC

VIII. Authorized Official

Name: SHANEKA TINCH
Title or Position: RCM MANAGER
Credential:
Phone: 469-458-9222