MEDICARE: ELITE 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1598304917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE PAIN MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	222 E PRIMROSE ST STE E
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-5233
Country	:	US
Telephone Number	:	417-888-0167
Fax Number	:	417-888-0189

Provider Business Practice Location Address
First Line	:	5780 OSAGE BEACH PKWY STE 113
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-3188
Country	:	US
Telephone Number	:	573-693-9080
Fax Number	:	417-888-0189

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	JENNIFER BOLIN
Credential	:
Telephone Number	:	417-888-0167

Provider Enumeration Date	:	01/02/2020
Last Update Date	:	01/02/2020

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