Provider Demographics
NPI:1689973042
Name:MD PAIN RELIEF CENTER, LLC
Entity Type:Organization
Organization Name:MD PAIN RELIEF CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GANG
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-302-0700
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:GLENELG
Mailing Address - State:MD
Mailing Address - Zip Code:21737-0100
Mailing Address - Country:US
Mailing Address - Phone:410-302-0700
Mailing Address - Fax:
Practice Address - Street 1:10760 HICKORY RIDGE RD
Practice Address - Street 2:SUITE 117
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3682
Practice Address - Country:US
Practice Address - Phone:410-302-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053730174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty