Provider Demographics
NPI:1962774745
Name:PAIN, INJURY & BRAIN CENTERS OF AMERICA MN LLC
Entity type:Organization
Organization Name:PAIN, INJURY & BRAIN CENTERS OF AMERICA MN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-269-1051
Mailing Address - Street 1:17838 25TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55929-1500
Mailing Address - Country:US
Mailing Address - Phone:507-269-1051
Mailing Address - Fax:
Practice Address - Street 1:14247 OCONNELL CT
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2878
Practice Address - Country:US
Practice Address - Phone:507-269-1051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain