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General NPI Number Information
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NPI Number | 1003851163
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Entity Type | Organization
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Legal Business Name | INNOVATIVE PAIN CENTER LLC
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Dates
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Enumeration Date | 06/20/2006
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Last Update Date | 12/22/2010
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Provider Practice Location Address
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Address Line | 1512 4TH ST NE
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City | WATERTOWN
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State | SD
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Zip | 57201-6824
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Country | US
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Telephone | 605-884-0100
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Fax |
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Provider Business Mailing Address
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Address Line | 1201 MICKELSON DR STE 2
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City | WATERTOWN
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State | SD
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Zip | 57201-7253
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Country | US
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Telephone | 605-882-0432
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Fax | 605-882-0978
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Authorized Official
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Title or Position | PROVIDER
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Name | PATRICK L RETTERATH
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Credential | MD
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Telephone | 605-884-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 0425
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License Number State | SD
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