MEDICARE: ADVANCED PAIN CARE AND WELLNESS 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	208VP0000X	Pain Medicine Physician	MD.201475	LA

General Provider Information

NPI Number	:	1720372311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED PAIN CARE AND WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	1234 DEL ESTE AVE
Second Line	:	SUITE 201
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4828
Country	:	US
Telephone Number	:	225-243-5603
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 DEL ESTE AVE
Second Line	:	SUITE 201
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-4828
Country	:	US
Telephone Number	:	225-243-5603
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH ANGELA RUSSO-STRINGER
Credential	:	MD
Telephone Number	:	225-243-5603

Provider Enumeration Date	:	06/01/2011
Last Update Date	:	06/01/2011

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