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General NPI Number Information
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NPI Number | 1821717711
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Entity Type | Organization
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Legal Business Name | PAIN MANAGEMENT 360 LLC
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Dates
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Enumeration Date | 08/24/2022
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Last Update Date | 04/26/2024
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Provider Practice Location Address
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Address Line | 551 21ST ST
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City | HUNTINGTON
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State | WV
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Zip | 25703-1540
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Country | US
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Telephone | 917-935-7788
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Fax | 304-577-8615
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Provider Business Mailing Address
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Address Line | PO BOX 33821
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City | BELFAST
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State | ME
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Zip | 04915-0616
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Country | US
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Telephone | 888-488-8289
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Fax | 304-577-8615
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Authorized Official
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Title or Position | OWNER
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Name | RUDY MALAYIL
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Credential | MD
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Telephone | 917-645-2591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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