Provider Demographics
NPI:1003851163
Name:INNOVATIVE PAIN CENTER LLC
Entity Type:Organization
Organization Name:INNOVATIVE PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:RETTERATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-884-0100
Mailing Address - Street 1:1201 MICKELSON DR STE 2
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-7253
Mailing Address - Country:US
Mailing Address - Phone:605-882-0432
Mailing Address - Fax:605-882-0978
Practice Address - Street 1:1512 4TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6824
Practice Address - Country:US
Practice Address - Phone:605-884-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0425208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN73M96INOtherBCBS
SD4995163OtherBCBS
MN892980000Medicaid
SDS41717Medicare PIN
SD6323830001Medicare NSC
MN892980000Medicaid
MNC03455Medicare ID - Type UnspecifiedGROUP