MEDICARE: MONTGOMERY VILLAGE PAIN AND REHABILITATION CENTER 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	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1053655639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTGOMERY VILLAGE PAIN AND REHABILITATION CENTER LLC

Provider Business Mailing Address
First Line	:	19211 MONTGOMERY VILLAGE AVE
Second Line	:	SUITE B-12
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20886-5028
Country	:	US
Telephone Number	:	240-477-5452
Fax Number	:

Provider Business Practice Location Address
First Line	:	19211 MONTGOMERY VILLAGE AVE
Second Line	:	SUITE B-12
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20886-5028
Country	:	US
Telephone Number	:	240-477-5452
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	PATRICK ESKEW
Credential	:
Telephone Number	:	301-625-5390

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	02/25/2015

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