Provider Demographics
NPI:1073568325
Name:HEADACHE & PAIN CENTER, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HEADACHE & PAIN CENTER, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:NOLAN
Authorized Official - Last Name:PONDER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:985-580-1200
Mailing Address - Street 1:123 FRONTAGE A RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:LA
Mailing Address - Zip Code:70359-6301
Mailing Address - Country:US
Mailing Address - Phone:985-580-1200
Mailing Address - Fax:985-580-1218
Practice Address - Street 1:123 FRONTAGE A RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359-6301
Practice Address - Country:US
Practice Address - Phone:985-580-1200
Practice Address - Fax:985-580-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB5621OtherBC/BS PROVIDER NUMBER
LA1441708Medicaid
6402090001Medicare NSC
LA5D885Medicare ID - Type UnspecifiedMEDICARE GRP PROV NUMBER