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General NPI Number Information
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NPI Number | 1184867319
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Entity Type | Organization
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Legal Business Name | PAIN AND BRAIN HEALING CENTER, LLC
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Dates
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Enumeration Date | 04/17/2009
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Last Update Date | 05/01/2015
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Provider Practice Location Address
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Address Line | 1400 131ST AVE NE
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City | BLAINE
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State | MN
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Zip | 55449-4124
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Country | US
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Telephone | 763-862-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 131ST AVE NE
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City | BLAINE
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State | MN
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Zip | 55449-4124
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Country | US
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Telephone | 763-862-7100
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Fax | 763-862-7077
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. GREGORY CHARLES FORS
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Credential | DC
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Telephone | 763-862-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1836
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License Number State | MN
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