=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679995088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKSBURG CENTER FOR PAIN MANAGEMENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2014
-----------------------------------------------------
Last Update Date | 01/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 S MAIN ST SUITE 8
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-605-9773
-----------------------------------------------------
Fax | 540-605-9777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 S MAIN ST SUITE 8
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-605-9773
-----------------------------------------------------
Fax | 540-605-9777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DON BIVINS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 540-605-9773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 0101029470
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------