Provider Demographics
NPI:1518300185
Name:PAIN AND HEADACHE CENTER, LLC
Entity Type:Organization
Organization Name:PAIN AND HEADACHE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-622-3715
Mailing Address - Street 1:851 E WESTPOINT DR STE B6
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7191
Mailing Address - Country:US
Mailing Address - Phone:907-357-3740
Mailing Address - Fax:800-915-0385
Practice Address - Street 1:851 E WESTPOINT DR STE B6
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7191
Practice Address - Country:US
Practice Address - Phone:907-357-3740
Practice Address - Fax:800-915-0385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10011620208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1583935Medicaid