Provider Demographics
NPI:1740645621
Name:VITAL PAIN CENTER, LLC
Entity type:Organization
Organization Name:VITAL PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:RIVERO BECERRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-595-9244
Mailing Address - Street 1:363 VANADIUM RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15243-1497
Mailing Address - Country:US
Mailing Address - Phone:412-279-1231
Mailing Address - Fax:412-276-0935
Practice Address - Street 1:363 VANADIUM RD
Practice Address - Street 2:SUITE 106
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15243-1497
Practice Address - Country:US
Practice Address - Phone:412-279-1231
Practice Address - Fax:412-276-0935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD441214208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027556710001Medicaid
246620FG3Medicare Oscar/Certification