Provider Demographics
NPI:1114553229
Name:PAIN GPS CLINIC, LLC
Entity Type:Organization
Organization Name:PAIN GPS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:702-339-8602
Mailing Address - Street 1:PO BOX 5029
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-0029
Mailing Address - Country:US
Mailing Address - Phone:702-339-8602
Mailing Address - Fax:
Practice Address - Street 1:1607 OAK ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4022
Practice Address - Country:US
Practice Address - Phone:541-246-3400
Practice Address - Fax:541-246-3421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-20
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1639647449Medicaid