Provider Demographics
NPI:1205339074
Name:PRO PAIN LLC
Entity type:Organization
Organization Name:PRO PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEDEFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-442-5035
Mailing Address - Street 1:4800 MEXICO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1666
Mailing Address - Country:US
Mailing Address - Phone:636-442-5035
Mailing Address - Fax:
Practice Address - Street 1:1055 BOWLES AVE STE 202
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2308
Practice Address - Country:US
Practice Address - Phone:636-326-7821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-17
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty