Healthcare Provider Details

I. General information

NPI: 1306237938
Provider Name (Legal Business Name): LIFELINC PAIN MANAGEMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 NORTHCREST DR
SPRINGFIELD TN
37172-3963
US

IV. Provider business mailing address

3340 PLAYERS CLUB PKWY SUITE 350
MEMPHIS TN
38125-8933
US

V. Phone/Fax

Practice location:
  • Phone: 866-362-6963
  • Fax: 866-362-4202
Mailing address:
  • Phone: 901-844-1590
  • Fax: 901-844-1592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: ERIC CALLAN
Title or Position: OWNER, CEO
Credential: CRNA
Phone: 901-844-1590