Provider Demographics
NPI:1639818040
Name:PAUSE PAIN AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:PAUSE PAIN AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:GAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-286-7916
Mailing Address - Street 1:1220 E NORTHSIDE DRIVE
Mailing Address - Street 2:SUITE 129 PMB#162
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211
Mailing Address - Country:US
Mailing Address - Phone:321-286-7916
Mailing Address - Fax:
Practice Address - Street 1:101 RICKY BRITT SR BLVD.
Practice Address - Street 2:SUITE 2
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:866-212-0685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1330513OtherBUSINESS ID