=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083958706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | O'FALLON PAIN RELIEF ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2012
-----------------------------------------------------
Last Update Date | 11/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2682 BABBLE CREEK LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-8337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-978-3000
-----------------------------------------------------
Fax | 636-978-1821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2682 BABBLE CREEK LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-8337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-978-3000
-----------------------------------------------------
Fax | 636-978-1821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AARON MOHR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 636-978-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------