=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619448842
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN PAIN CONSULTANTS. LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 S BROADWAY UNIT 11007
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80113-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-459-2874
-----------------------------------------------------
Fax | 303-422-6683
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3330 S BROADWAY UNIT 11007
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80113-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-459-2874
-----------------------------------------------------
Fax | 303-422-6683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JONATHAN CLAPP
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 720-459-2874
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------