Healthcare Provider Details

I. General information

NPI: 1114236247
Provider Name (Legal Business Name): BECKLEY PAIN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 HARPER RD SUITE D
BECKLEY WV
25801-2642
US

IV. Provider business mailing address

1902 HARPER RD SUITE D
BECKLEY WV
25801-2642
US

V. Phone/Fax

Practice location:
  • Phone: 304-894-8817
  • Fax:
Mailing address:
  • Phone: 304-894-8817
  • Fax: 304-894-8924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. PRAKASH PURANIK
Title or Position: PRESIDENT
Credential: MD
Phone: 304-237-2063