Provider Demographics
NPI:1508101734
Name:PREFERRED PAIN CENTER OF GRUNDY COUNTY
Entity Type:Organization
Organization Name:PREFERRED PAIN CENTER OF GRUNDY COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-779-2225
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:GRUETLI LAAGER
Mailing Address - State:TN
Mailing Address - Zip Code:37339-0258
Mailing Address - Country:US
Mailing Address - Phone:931-779-2225
Mailing Address - Fax:931-779-2226
Practice Address - Street 1:32717 SR 108
Practice Address - Street 2:
Practice Address - City:GRUETLI LAAGER
Practice Address - State:TN
Practice Address - Zip Code:37339
Practice Address - Country:US
Practice Address - Phone:931-779-2225
Practice Address - Fax:931-779-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN208VP0000X, 363A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6766500001Medicare NSC
TN10370G4159Medicare PIN