1063689511 NPI number — ADVANCED PAIN CLINIC PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063689511 NPI number — ADVANCED PAIN CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PAIN CLINIC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063689511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 W VINE ST
Provider Second Line Business Mailing Address:
301
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34741-4123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-935-9404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 E COLONIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32803-5245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-935-9404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RAJYAGURU
Authorized Official First Name:
VRAJLAL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
407-935-9404

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  ME0066759 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 377046000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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