Provider Demographics
NPI:1124275565
Name:COMPREHENSIVE PAIN CENTER OF MISSISSIPPI
Entity type:Organization
Organization Name:COMPREHENSIVE PAIN CENTER OF MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONEL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:769-300-0730
Mailing Address - Street 1:129 FOUNTAINS BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-949-9994
Mailing Address - Fax:
Practice Address - Street 1:129 FOUNTAINS BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:769-300-0730
Practice Address - Fax:601-949-2782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16855208VP0014X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2389791Medicaid