Provider Demographics
NPI:1174988539
Name:PRIMARY PAIN SOLUTIONS LLC
Entity type:Organization
Organization Name:PRIMARY PAIN SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RISVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-529-1898
Mailing Address - Street 1:PO BOX 100216
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99510-0216
Mailing Address - Country:US
Mailing Address - Phone:907-529-1898
Mailing Address - Fax:800-861-3488
Practice Address - Street 1:7810 CANAL ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-4261
Practice Address - Country:US
Practice Address - Phone:907-529-1898
Practice Address - Fax:800-861-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5124261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain