Provider Demographics
NPI:1861752032
Name:SURGICAL AND PAIN TREATMENT CENTER OF CLARKSVILLE
Entity type:Organization
Organization Name:SURGICAL AND PAIN TREATMENT CENTER OF CLARKSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-905-1720
Mailing Address - Street 1:2269 WILMA RUDOLPH BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3179
Mailing Address - Country:US
Mailing Address - Phone:931-905-1720
Mailing Address - Fax:931-905-1721
Practice Address - Street 1:2269 WILMA RUDOLPH BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3179
Practice Address - Country:US
Practice Address - Phone:931-905-1720
Practice Address - Fax:931-905-1721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR HEALTHCARE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain