Provider Demographics
NPI:1740245125
Name:PAIN TREATMENT & REHABILITATION CENTER,PA
Entity Type:Organization
Organization Name:PAIN TREATMENT & REHABILITATION CENTER,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-283-3300
Mailing Address - Street 1:D71 OMEGA DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-283-3300
Mailing Address - Fax:302-283-3321
Practice Address - Street 1:71 OMEGA DR
Practice Address - Street 2:BUILDING D
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2063
Practice Address - Country:US
Practice Address - Phone:302-283-3300
Practice Address - Fax:302-283-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE054476609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000023982Medicaid
DEH04716Medicare UPIN
DEG01265Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER