Provider Demographics
NPI:1609185412
Name:PAIN CARE NORTHWEST, LLC
Entity type:Organization
Organization Name:PAIN CARE NORTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUCIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-496-7268
Mailing Address - Street 1:PO BOX 971
Mailing Address - Street 2:
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098-0971
Mailing Address - Country:US
Mailing Address - Phone:860-496-7268
Mailing Address - Fax:860-379-4717
Practice Address - Street 1:142 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4520
Practice Address - Country:US
Practice Address - Phone:860-496-7268
Practice Address - Fax:860-379-4717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035144208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001177Medicare UPIN