1962589671 NPI number — PREMIER PAIN SPECIALISTS LLC

Table of content: (NPI 1962589671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962589671 NPI number — PREMIER PAIN SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PAIN SPECIALISTS 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:
1962589671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1228 SE 8TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33990-3210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-945-1105
Provider Business Mailing Address Fax Number:
239-945-4495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1228 SE 8TH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE CORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33990-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-945-1105
Provider Business Practice Location Address Fax Number:
239-945-4495
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PREUDHOMME
Authorized Official First Name:
JULES
Authorized Official Middle Name:
ALVA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-945-1105

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  ME72077 , 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: 1132487 . This is a "FIRST HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0403035 . This is a "WORKERS COMPENSATON" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 352107800 . This is a "ACS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 050085760 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 43550 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 285839 . This is a "BC/BS VIRTUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7040371 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P2816206 . This is a "OXFORD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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