MEDICARE: PAIN INSTITUTE OF NEVADA, INC.

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	:	1376571331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN INSTITUTE OF NEVADA, INC.

Provider Business Mailing Address
First Line	:	7435 W AZURE DR STE 190
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-4427
Country	:	US
Telephone Number	:	702-878-8252
Fax Number	:	702-878-9096

Provider Business Practice Location Address
First Line	:	7065 W ANN RD STE 130-548
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130
Country	:	US
Telephone Number	:	702-878-8252
Fax Number	:	702-878-9096

Authorized Official
Title or Position	:	OWNER PRES CEO
Name	:	WALTER M KIDWELL
Credential	:	MD
Telephone Number	:	702-878-8252

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	06/12/2019

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