1699708693 NPI number — PAIN MANAGEMENT SPECIALISTS OF NORTH FLORIDA P A

Table of content: KRISTOPHER GERALD BALGAARD PT (NPI 1053495564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699708693 NPI number — PAIN MANAGEMENT SPECIALISTS OF NORTH FLORIDA P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT SPECIALISTS OF NORTH FLORIDA P A
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:
1699708693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 PLANTATION ISLAND DR S
Provider Second Line Business Mailing Address:
SUITE 301A
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32080-3117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-460-9555
Provider Business Mailing Address Fax Number:
904-460-0090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 PLANTATION ISLAND DR S STE 301A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32080-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-460-9555
Provider Business Practice Location Address Fax Number:
904-460-0090
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONZON
Authorized Official First Name:
RAUL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-460-9555

Provider Taxonomy Codes

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

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





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