Healthcare Provider Details

I. General information

NPI: 1144756768
Provider Name (Legal Business Name): PAIN CENTER OF VIRGINIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 WEST PLAZA DRIVE
WINCHESTER VA
22601
US

IV. Provider business mailing address

1000 TAVERN RD SUITE 300
MARTINSBURG WV
25401-2845
US

V. Phone/Fax

Practice location:
  • Phone: 540-773-2689
  • Fax: 540-486-4166
Mailing address:
  • Phone: 304-263-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25285
License Number StateWV

VIII. Authorized Official

Name: AMANDA LARRICK
Title or Position: PRACTICE COORDINATOR
Credential:
Phone: 304-263-6165