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General NPI Number Information
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NPI Number | 1679863773
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Entity Type | Organization
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Legal Business Name | PAIN RELIEF AND WELLNESS OF MINNESOTA
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Dates
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Enumeration Date | 04/11/2011
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Last Update Date | 02/13/2014
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Provider Practice Location Address
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Address Line | 4721 CLARK AVE
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-3221
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Country | US
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Telephone | 651-249-0454
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Fax | 651-560-7013
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Provider Business Mailing Address
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Address Line | 4721 CLARK AVE
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-3221
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Country | US
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Telephone | 651-788-6689
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Fax | 651-560-7013
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Authorized Official
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Title or Position | OWNER/MD
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Name | DR. ADAM JASON LOCKETZ
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Credential | MD
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Telephone | 651-249-0454
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State | MN
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