MEDICARE: PAIN CARE 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	:	1992039721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN CARE CENTER,LLC

Provider Business Mailing Address
First Line	:	2140 HOLLOW BROOK DR
Second Line	:	SUITE 110
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1452
Country	:	US
Telephone Number	:	719-434-3636
Fax Number	:	719-434-3639

Provider Business Practice Location Address
First Line	:	2140 HOLLOW BROOK DR
Second Line	:	SUITE 110
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1452
Country	:	US
Telephone Number	:	719-434-3636
Fax Number	:	719-434-3639

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL E LAFAYETTE
Credential	:	FNP
Telephone Number	:	719-434-3636

Provider Enumeration Date	:	09/27/2009
Last Update Date	:	03/20/2014

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