Healthcare Provider Details

I. General information

NPI: 1114233228
Provider Name (Legal Business Name): JACKSON INTERVENTIONAL PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 HOSPITAL BLVD
JACKSON TN
38305-2177
US

IV. Provider business mailing address

379 HOSPITAL BLVD
JACKSON TN
38305-2080
US

V. Phone/Fax

Practice location:
  • Phone: 731-267-0222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC HOMBERG
Title or Position: OWNER
Credential: MD
Phone: 731-267-0222