Provider Demographics
NPI:1033409198
Name:FOUR STATES PAIN RELIEF INSTITUTE, LLC
Entity Type:Organization
Organization Name:FOUR STATES PAIN RELIEF INSTITUTE, LLC
Other - Org Name:4 CORNERS PAIN RELIEF INSTITUTE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUDSEN III
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-624-4277
Mailing Address - Street 1:1515 E 32ND ST
Mailing Address - Street 2:STE B
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2905
Mailing Address - Country:US
Mailing Address - Phone:417-624-4277
Mailing Address - Fax:417-624-4297
Practice Address - Street 1:2650 E 32ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4313
Practice Address - Country:US
Practice Address - Phone:417-624-4277
Practice Address - Fax:417-624-4297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty