Provider Demographics
NPI:1972717189
Name:COMPREHENSIVE PAIN CARE CENTER, INC
Entity Type:Organization
Organization Name:COMPREHENSIVE PAIN CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-989-2066
Mailing Address - Street 1:4804 LEAVITT RD
Mailing Address - Street 2:STE A
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053
Mailing Address - Country:US
Mailing Address - Phone:440-989-2066
Mailing Address - Fax:440-989-1153
Practice Address - Street 1:5334 MEADOW LANE CT
Practice Address - Street 2:STE 200
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1469
Practice Address - Country:US
Practice Address - Phone:440-934-8922
Practice Address - Fax:440-934-8949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2648657Medicaid
OH=========01OtherBWC SHEFFIELD OFF
OH9324141Medicare ID - Type UnspecifiedGROUP PRACTICE ID