Provider Demographics
NPI:1871135947
Name:CHOICE PAIN & REBABILITATION CENTER LLC
Entity type:Organization
Organization Name:CHOICE PAIN & REBABILITATION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-786-1001
Mailing Address - Street 1:9123 OLD ANNAPOLIS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1970
Mailing Address - Country:US
Mailing Address - Phone:410-505-8605
Mailing Address - Fax:
Practice Address - Street 1:9123 OLD ANNAPOLIS RD STE 203
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-1970
Practice Address - Country:US
Practice Address - Phone:410-505-8605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHOICE PAIN & REHABILITATION CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-10
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder