1114159118 NPI number — OPA-LOCKA PAIN MANAGEMENT, CORP

Table of content: (NPI 1114159118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114159118 NPI number — OPA-LOCKA PAIN MANAGEMENT, CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPA-LOCKA PAIN MANAGEMENT, CORP
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:
6
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:
1114159118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1865 NE 163RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33162-4805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-948-9958
Provider Business Mailing Address Fax Number:
305-948-9518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1865 NE 163RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MIAMI BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33162-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-948-9958
Provider Business Practice Location Address Fax Number:
305-948-9518
Provider Enumeration Date:
08/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PADRON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
DIRECTOR/OWNER
Authorized Official Telephone Number:
305-948-9958

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME050431 , 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: 08587 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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