Healthcare Provider Details

I. General information

NPI: 1831433283
Provider Name (Legal Business Name): MCMINNVILLE PAIN RELIEF CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2012
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 SPARTA ST STE 4
MCMINNVILLE TN
37110-2698
US

IV. Provider business mailing address

810 SPARTA ST STE 4
MCMINNVILLE TN
37110-2698
US

V. Phone/Fax

Practice location:
  • Phone: 931-474-1616
  • Fax: 931-474-1618
Mailing address:
  • Phone: 931-474-1616
  • Fax: 931-474-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: MR. MATT ANDERSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 931-474-1616