1639333859 NPI number — PAIN MANAGEMENT INSTITUTE LLC

Table of content: (NPI 1639333859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639333859 NPI number — PAIN MANAGEMENT INSTITUTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT INSTITUTE 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:
1639333859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 JENNINGS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUSTIS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32726-6148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-357-0668
Provider Business Mailing Address Fax Number:
352-357-3643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 JENNINGS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32726-6148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-357-0668
Provider Business Practice Location Address Fax Number:
352-357-3643
Provider Enumeration Date:
07/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HANFLINK
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
JOSHUA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-357-0668

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  OS9725 , 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: 004178500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10D1088106 . This is a "CLIA-CERTIFICATE OF WAIVER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DP7786 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1036842 . This is a "NON-PHARMACY DISPENSING SITE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: BH086 . This is a "PTAN-GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: JR44088000 . This is a "FL DOH-RADIATION MACHINE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PMC1328 . This is a "FL DOH-PAIN MANAGEMENT CLINIC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 017031300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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