1578872602 NPI number — PAIN CARE MANAGEMENT OF MELBOURNE, LLC

Table of content: (NPI 1578872602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578872602 NPI number — PAIN CARE MANAGEMENT OF MELBOURNE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN CARE MANAGEMENT OF MELBOURNE, 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:
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:
1578872602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5036 DR PHILLIPS BLVD
Provider Second Line Business Mailing Address:
SUITE 337
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32819-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-251-4462
Provider Business Mailing Address Fax Number:
888-469-1872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3150 N WICKHAM RD
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-773-4134
Provider Business Practice Location Address Fax Number:
321-574-5611
Provider Enumeration Date:
10/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
C
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
321-251-4462

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  PMC1568 , 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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