Provider Demographics
NPI:1619203585
Name:NORTHERN LIGHTS PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:NORTHERN LIGHTS PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-770-9600
Mailing Address - Street 1:PO BOX 71434
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-1434
Mailing Address - Country:US
Mailing Address - Phone:907-770-9600
Mailing Address - Fax:907-277-2629
Practice Address - Street 1:1320 22ND AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6516
Practice Address - Country:US
Practice Address - Phone:907-452-4777
Practice Address - Fax:907-452-4787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK297874207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK297874OtherAK BUSINESS LICENSE