Provider Demographics
NPI:1710230800
Name:INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-229-1500
Mailing Address - Street 1:2301 CONNECTICUT AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2474
Mailing Address - Country:US
Mailing Address - Phone:320-229-1500
Mailing Address - Fax:320-229-1505
Practice Address - Street 1:2301 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2474
Practice Address - Country:US
Practice Address - Phone:320-229-1500
Practice Address - Fax:320-229-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies