MEDICARE: PROFESSIONAL PAIN MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	13528	TN

General Provider Information

NPI Number	:	1003109646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL PAIN MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	PO BOX 4350
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37320-4350
Country	:	US
Telephone Number	:	423-790-7500
Fax Number	:	423-790-5299

Provider Business Practice Location Address
First Line	:	301 KEITH ST SW
Second Line	:	SUITE 204
City	:	CLEVELAND
State	:	TN
Zip	:	37311-5808
Country	:	US
Telephone Number	:	423-790-7500
Fax Number	:	423-790-5299

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID S. COFER
Credential	:	NP
Telephone Number	:	423-790-7500

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	05/16/2011

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