Provider Demographics
NPI:1003109646
Name:PROFESSIONAL PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:COFER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:423-790-7500
Mailing Address - Street 1:PO BOX 4350
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-4350
Mailing Address - Country:US
Mailing Address - Phone:423-790-7500
Mailing Address - Fax:423-790-5299
Practice Address - Street 1:301 KEITH ST SW
Practice Address - Street 2:SUITE 204
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-5808
Practice Address - Country:US
Practice Address - Phone:423-790-7500
Practice Address - Fax:423-790-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty