Provider Demographics
NPI:1114236247
Name:BECKLEY PAIN CLINIC LLC
Entity Type:Organization
Organization Name:BECKLEY PAIN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:
Authorized Official - Last Name:PURANIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-237-2063
Mailing Address - Street 1:1902 HARPER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2642
Mailing Address - Country:US
Mailing Address - Phone:304-894-8817
Mailing Address - Fax:304-894-8924
Practice Address - Street 1:1902 HARPER RD
Practice Address - Street 2:SUITE D
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2642
Practice Address - Country:US
Practice Address - Phone:304-894-8817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9393411Medicare PIN