Healthcare Provider Details

I. General information

NPI: 1710165501
Provider Name (Legal Business Name): PREFERRED PAIN MANAGEMENT, P.A,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 CHARLOIS BLVD SUITE C
WINSTON SALEM NC
27103-1507
US

IV. Provider business mailing address

245 CHARLOIS BLVD SUITE C
WINSTON SALEM NC
27103-1507
US

V. Phone/Fax

Practice location:
  • Phone: 336-760-0706
  • Fax: 336-760-1927
Mailing address:
  • Phone: 336-760-0706
  • Fax: 336-760-1927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number30582
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID L. SPIVEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 336-760-0706