Provider Demographics
NPI:1679863773
Name:PAIN RELIEF AND WELLNESS OF MINNESOTA
Entity type:Organization
Organization Name:PAIN RELIEF AND WELLNESS OF MINNESOTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:LOCKETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-249-0454
Mailing Address - Street 1:4721 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3221
Mailing Address - Country:US
Mailing Address - Phone:651-788-6689
Mailing Address - Fax:651-560-7013
Practice Address - Street 1:4721 CLARK AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3221
Practice Address - Country:US
Practice Address - Phone:651-249-0454
Practice Address - Fax:651-560-7013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2081P2900X, 2081P2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34536300Medicaid
MN530615900Medicaid
MNH66508Medicare UPIN
MN090000028Medicare PIN