Provider Demographics
NPI:1134682677
Name:PAIN & REHAB CLINIC, LLC
Entity Type:Organization
Organization Name:PAIN & REHAB CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NESLY
Authorized Official - Middle Name:MI
Authorized Official - Last Name:CLERGE
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:314-520-4411
Mailing Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE STE 106
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-7022
Mailing Address - Country:US
Mailing Address - Phone:202-610-0260
Mailing Address - Fax:202-610-0261
Practice Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE STE 106
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7022
Practice Address - Country:US
Practice Address - Phone:202-610-0260
Practice Address - Fax:202-610-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty