1447863204 NPI number — CERTIFIED SPINE AND PAIN CARE, LLC

Table of content: (NPI 1447863204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447863204 NPI number — CERTIFIED SPINE AND PAIN CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CERTIFIED SPINE AND PAIN CARE, LLC
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:
1447863204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11211 PROSPERITY FARMS RD STE B104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-537-4526
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S MAIN ST STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLE GLADE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33430-4910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-578-4582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MALDONADO
Authorized Official First Name:
EDWIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-578-4562

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112488701 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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