Provider Demographics
NPI:1922144484
Name:INTERVENTIONAL PAIN CENTER OF CHESTERFIELD L L C
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN CENTER OF CHESTERFIELD L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DYDELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, CASC
Authorized Official - Phone:636-728-1977
Mailing Address - Street 1:17300 N OUTER 40 RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1364
Mailing Address - Country:US
Mailing Address - Phone:636-728-1977
Mailing Address - Fax:636-778-1488
Practice Address - Street 1:17300 N OUTER 40
Practice Address - Street 2:100
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1364
Practice Address - Country:US
Practice Address - Phone:636-728-1977
Practice Address - Fax:636-778-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3N29261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2500057564OtherBNDD
MO2500057564OtherBNDD
MOBS8421276OtherDEA#