Provider Demographics
NPI:1568771095
Name:KOKOMO PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:KOKOMO PAIN MANAGEMENT, LLC
Other - Org Name:MEDICAL PAIN AND SPINE CARE OF INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:KLIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-776-7028
Mailing Address - Street 1:18077 RIVER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-8334
Mailing Address - Country:US
Mailing Address - Phone:317-776-7028
Mailing Address - Fax:317-773-7910
Practice Address - Street 1:18077 RIVER RD STE 200
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8334
Practice Address - Country:US
Practice Address - Phone:317-776-7028
Practice Address - Fax:317-773-7910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002790A261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200998560Medicaid