Healthcare Provider Details

I. General information

NPI: 1003851163
Provider Name (Legal Business Name): INNOVATIVE PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 4TH ST NE
WATERTOWN SD
57201-6824
US

IV. Provider business mailing address

1201 MICKELSON DR STE 2
WATERTOWN SD
57201-7253
US

V. Phone/Fax

Practice location:
  • Phone: 605-884-0100
  • Fax:
Mailing address:
  • Phone: 605-882-0432
  • Fax: 605-882-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number0425
License Number StateSD

VIII. Authorized Official

Name: PATRICK L RETTERATH
Title or Position: PROVIDER
Credential: MD
Phone: 605-884-0100