Provider Demographics
NPI:1972046803
Name:WHITE MOUNTAIN PAIN CLINIC, PLLC
Entity type:Organization
Organization Name:WHITE MOUNTAIN PAIN CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GRANTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DAAETS
Authorized Official - Phone:205-567-0832
Mailing Address - Street 1:PO BOX 531166
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BROOK
Mailing Address - State:AL
Mailing Address - Zip Code:35253-1166
Mailing Address - Country:US
Mailing Address - Phone:205-567-0832
Mailing Address - Fax:
Practice Address - Street 1:5721 5TH CT S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35212-3211
Practice Address - Country:US
Practice Address - Phone:205-567-0832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-25
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-083260261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain