Healthcare Provider Details

I. General information

NPI: 1710050737
Provider Name (Legal Business Name): THE PELVIC PAIN AND RECONSTRUCTIVE SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 GUNBARREL RD SUITE 202
CHATTANOOGA TN
37421-7137
US

IV. Provider business mailing address

1755 GUNBARREL RD SUITE 202
CHATTANOOGA TN
37421-7137
US

V. Phone/Fax

Practice location:
  • Phone: 423-490-1136
  • Fax:
Mailing address:
  • Phone: 423-490-1136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number024075
License Number StateTN

VIII. Authorized Official

Name: ALFREDO NIEVES
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 423-490-1136