=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578886180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSSEX PAIN RELIEF CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2010
-----------------------------------------------------
Last Update Date | 10/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18229 DUPONT BLVD
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-519-1616
-----------------------------------------------------
Fax | 302-253-8028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18229 DUPONT BLVD
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19947-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-514-7246
-----------------------------------------------------
Fax | 302-253-8028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MANONMANI ANTONY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 302-519-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------