Provider Demographics
NPI:1366274839
Name:THE JAW PAIN PRO LLC
Entity type:Organization
Organization Name:THE JAW PAIN PRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-553-0009
Mailing Address - Street 1:4137 CARMICHAEL RD STE 320
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3614
Mailing Address - Country:US
Mailing Address - Phone:334-865-9872
Mailing Address - Fax:
Practice Address - Street 1:4137 CARMICHAEL RD STE 320
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3614
Practice Address - Country:US
Practice Address - Phone:334-865-9872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty