Provider Demographics
NPI:1669864948
Name:PAUL MITCHELL PAIN MANAGEMENT, P.A.
Entity Type:Organization
Organization Name:PAUL MITCHELL PAIN MANAGEMENT, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:843-415-8511
Mailing Address - Street 1:15 MOSS CREEK VLG
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1105
Mailing Address - Country:US
Mailing Address - Phone:843-415-8511
Mailing Address - Fax:800-820-0148
Practice Address - Street 1:15 MOSS CREEK VLG
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-1105
Practice Address - Country:US
Practice Address - Phone:843-415-8511
Practice Address - Fax:800-820-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00666174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty