Provider Demographics
NPI:1073976601
Name:SHAKOPEE PAIN CLINIC
Entity type:Organization
Organization Name:SHAKOPEE PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRIENTEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-777-2990
Mailing Address - Street 1:255 1ST AVE E
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1440
Mailing Address - Country:US
Mailing Address - Phone:952-777-2990
Mailing Address - Fax:
Practice Address - Street 1:255 1ST AVE E
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1440
Practice Address - Country:US
Practice Address - Phone:952-777-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN866867100036302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization