Provider Demographics
NPI:1780704619
Name:WYOMING VALLEY PAIN CLINIC & REHABILITATION CENTER
Entity type:Organization
Organization Name:WYOMING VALLEY PAIN CLINIC & REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-822-9514
Mailing Address - Street 1:39 S RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1233
Mailing Address - Country:US
Mailing Address - Phone:570-822-9514
Mailing Address - Fax:570-823-8039
Practice Address - Street 1:39 S RIVER ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1233
Practice Address - Country:US
Practice Address - Phone:570-822-9514
Practice Address - Fax:570-823-8039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026644E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA459803Medicare ID - Type UnspecifiedMEDICARE #
PAC34373Medicare UPIN