Basic Information
| Provider Information | |||||||||
| NPI: | 1255608816 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 828 WALK IN CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PAINSTOP SPINE CLINIC, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4594 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395354594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282734096 | ||||||||
| FaxNumber: | 8668097246 | ||||||||
| Practice Location | |||||||||
| Address1: | 12207 HWY 49 | ||||||||
| Address2: | SUITE 40 | ||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288328872 | ||||||||
| FaxNumber: | 8668097246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | TSANG | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2282734096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PAINSTOP SPINE CLINIC, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R791344 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207LP2900X | 14282 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00114733 | 05 | MS | MEDICAID | 04078379 | 05 | MS | MEDICAID |