Organization
PAIN CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MONICA R FORMON (ADMINISTRATOR)
(870) 972-0411
Entity
Organization
Contact information
Practice address
505 E MATTHEWS AVE, SUITE 103, JONESBORO, AR 72401-3144
(870) 972-0411
(870) 933-8011
Mailing address
505 E MATTHEWS AVE, SUITE 103, JONESBORO, AR 72401-3144
(870) 972-0411
(870) 933-8011
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
AR4148
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0213069
DEPT OF LABOR WA
AR
01
—
11000
BLUE CROSS PROVIDER NUMBE
AR
05
—
150029128
—
AR
Enumeration date
10/16/2006
Last updated
11/10/2010
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