Provider Demographics
NPI:1730355298
Name:THREE RIVERS PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:THREE RIVERS PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-454-1661
Mailing Address - Street 1:169 MEDICAL CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3655
Mailing Address - Country:US
Mailing Address - Phone:803-454-1661
Mailing Address - Fax:803-454-1660
Practice Address - Street 1:169 MEDICAL CIR
Practice Address - Street 2:SUITE A
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3655
Practice Address - Country:US
Practice Address - Phone:803-454-1661
Practice Address - Fax:803-454-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17489208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC17489OtherSTATE LISCENSE NUMBER
SC8327OtherPROVIDER NUMBER
SC17489OtherSTATE LISCENSE NUMBER