Provider Demographics
NPI:1902356868
Name:METRO MN PAIN CENTER, LLC
Entity Type:Organization
Organization Name:METRO MN PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:763-951-2308
Mailing Address - Street 1:3260 COUNTY ROAD 10
Mailing Address - Street 2:SUITE G
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3076
Mailing Address - Country:US
Mailing Address - Phone:763-951-2308
Mailing Address - Fax:763-951-2378
Practice Address - Street 1:3260 COUNTY ROAD 10
Practice Address - Street 2:SUITE G
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3076
Practice Address - Country:US
Practice Address - Phone:763-951-2308
Practice Address - Fax:763-951-2378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4713271261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain