Provider Demographics
NPI:1780766493
Name:PAIN RELIEF CENTER OF AMERICA, INC
Entity type:Organization
Organization Name:PAIN RELIEF CENTER OF AMERICA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-869-3000
Mailing Address - Street 1:211 60TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2805
Mailing Address - Country:US
Mailing Address - Phone:201-869-3000
Mailing Address - Fax:201-869-3001
Practice Address - Street 1:211 60TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2805
Practice Address - Country:US
Practice Address - Phone:201-869-3000
Practice Address - Fax:201-869-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0400146384207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1629188503OtherNPI
NJ77331001Medicaid
020397Medicare ID - Type Unspecified
NJ77331001Medicaid