1629093596 NPI number — PALM BEACH PAIN MANAGEMENT INC

Table of content: (NPI 1629093596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629093596 NPI number — PALM BEACH PAIN MANAGEMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM BEACH PAIN MANAGEMENT INC
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:
1629093596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PALM BEACH PAIN MANAGEMENT
Provider Second Line Business Mailing Address:
907 NORTH FEDERAL HWY
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-335-7246
Provider Business Mailing Address Fax Number:
772-335-7202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PALM BEACH PAIN MANAGEMENT
Provider Second Line Business Practice Location Address:
907 N. FEDERAL HWY
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-292-3747
Provider Business Practice Location Address Fax Number:
561-292-3730
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANCE
Authorized Official First Name:
DARLENE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
772-335-7246

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004743700 . 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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