Healthcare Provider Details

I. General information

NPI: 1285914697
Provider Name (Legal Business Name): PAIN RELIEF OF WEST TN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 VICKSBURG AVE
CAMDEN TN
38320-1614
US

IV. Provider business mailing address

116 VICKSBURG AVE
CAMDEN TN
38320-1614
US

V. Phone/Fax

Practice location:
  • Phone: 731-441-6317
  • Fax: 731-937-4510
Mailing address:
  • Phone: 731-441-6317
  • Fax: 731-937-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number8034
License Number StateTN

VIII. Authorized Official

Name: MS. BRENDA C MONTGOMERY
Title or Position: OWNER/MGR
Credential:
Phone: 731-441-6317