Healthcare Provider Details

I. General information

NPI: 1730355298
Provider Name (Legal Business Name): THREE RIVERS PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 MEDICAL CIR SUITE A
WEST COLUMBIA SC
29169-3655
US

IV. Provider business mailing address

169 MEDICAL CIR SUITE A
WEST COLUMBIA SC
29169-3655
US

V. Phone/Fax

Practice location:
  • Phone: 803-454-1661
  • Fax: 803-454-1660
Mailing address:
  • Phone: 803-454-1661
  • Fax: 803-454-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number17489
License Number StateSC

VIII. Authorized Official

Name: MRS. DONNA M. WARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-454-1661