1629254818 NPI number — COASTAL PAIN MANAGEMENT DELRAY DISPENSARY

Table of content: (NPI 1629254818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629254818 NPI number — COASTAL PAIN MANAGEMENT DELRAY DISPENSARY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL PAIN MANAGEMENT DELRAY DISPENSARY
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:
1629254818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4688
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33338-4688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-376-7313
Provider Business Mailing Address Fax Number:
954-697-0153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 NE 6TH AVE
Provider Second Line Business Practice Location Address:
SUITE #104
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33483-5435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-272-3880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EASON
Authorized Official First Name:
CICELY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
EXECUTIVE ADMINISTRATOR
Authorized Official Telephone Number:
561-789-4911

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  ME62450 , 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)





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