Provider Demographics
NPI:1972030062
Name:LAFAYETTE PAIN CARE PC
Entity Type:Organization
Organization Name:LAFAYETTE PAIN CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAZIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-714-4344
Mailing Address - Street 1:770 PARK EAST BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-0786
Mailing Address - Country:US
Mailing Address - Phone:765-714-4344
Mailing Address - Fax:765-838-3200
Practice Address - Street 1:613 TERRACE DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1111
Practice Address - Country:US
Practice Address - Phone:574-946-4290
Practice Address - Fax:574-946-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-19
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies