1033309570 NPI number — PAIN MANAGEMENT INSTITUTE OF ORLANDO LLC

Table of content: (NPI 1033309570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033309570 NPI number — PAIN MANAGEMENT INSTITUTE OF ORLANDO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT INSTITUTE OF ORLANDO 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:
1033309570
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3123
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32085-3123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-824-4990
Provider Business Mailing Address Fax Number:
904-824-2226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 E CENTRAL PKWY STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32701-3449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-671-5115
Provider Business Practice Location Address Fax Number:
407-671-5116
Provider Enumeration Date:
07/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURRY
Authorized Official First Name:
JULIET
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
407-671-5115

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  ME85974 , 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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