Provider Demographics
NPI:1235226994
Name:PAIN MANAGEMENT JOINT VENTURE, LLP
Entity Type:Organization
Organization Name:PAIN MANAGEMENT JOINT VENTURE, LLP
Other - Org Name:CENTRE OF REHABILITATION EXCELLENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-753-6635
Mailing Address - Street 1:3206 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5143
Mailing Address - Country:US
Mailing Address - Phone:903-753-6635
Mailing Address - Fax:903-753-1114
Practice Address - Street 1:123 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:LONE STAR
Practice Address - State:TX
Practice Address - Zip Code:75668
Practice Address - Country:US
Practice Address - Phone:903-656-2419
Practice Address - Fax:903-656-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5500600000225X00000X
TX225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-6819Medicare ID - Type Unspecified