Provider Demographics
NPI:1003255480
Name:EAGLE RIVER PAIN & WELLNESS, LLC
Entity Type:Organization
Organization Name:EAGLE RIVER PAIN & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:SPAYD
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-622-4673
Mailing Address - Street 1:16425 BROOKS LOOP
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8027
Mailing Address - Country:US
Mailing Address - Phone:907-622-4673
Mailing Address - Fax:907-622-4674
Practice Address - Street 1:16425 BROOKS LOOP
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8027
Practice Address - Country:US
Practice Address - Phone:907-622-4673
Practice Address - Fax:907-622-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK308947363L00000X
AK0588363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1584697Medicaid