1417082454 NPI number — SERVICE PAIN HEALING LABRA INC

Table of content: (NPI 1417082454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417082454 NPI number — SERVICE PAIN HEALING LABRA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVICE PAIN HEALING LABRA INC
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:
1417082454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 S DIXIE HWY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
LAKE WORTH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33460-4154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-584-0315
Provider Business Mailing Address Fax Number:
305-675-2668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 S DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LAKE WORTH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33460-4154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-584-0315
Provider Business Practice Location Address Fax Number:
305-675-2668
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
OSVALDO
Authorized Official Middle Name:
LABRADOR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-584-0316

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  HCC7523 , 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: HCC7523 . This is a "AHCA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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