Provider Demographics
NPI:1891390118
Name:PAIN CARE CENTER LLC
Entity Type:Organization
Organization Name:PAIN CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:CHET
Authorized Official - Last Name:RUGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-267-2116
Mailing Address - Street 1:2620 COMMERCIAL WAY STE 20
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4705
Mailing Address - Country:US
Mailing Address - Phone:307-212-6270
Mailing Address - Fax:
Practice Address - Street 1:945 W BROADWAY AVE APT 202
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8217
Practice Address - Country:US
Practice Address - Phone:307-212-6270
Practice Address - Fax:307-212-6271
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAIN CARE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY132443800Medicaid