Provider Demographics
NPI:1508009614
Name:PEE DEE PAIN CARE, LLC
Entity Type:Organization
Organization Name:PEE DEE PAIN CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-350-0100
Mailing Address - Street 1:PO BOX 100523
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-0523
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:
Practice Address - Street 1:552 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-5412
Practice Address - Country:US
Practice Address - Phone:843-350-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23676208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC236765Medicaid
SC236765Medicaid
SCH81512Medicare UPIN
SC7378100001Medicare NSC