1841328002 NPI number — SPACE COAST PAIN RELIEF INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841328002 NPI number — SPACE COAST PAIN RELIEF INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST PAIN RELIEF 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:
1841328002
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:
3550 S WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 24
Provider Business Mailing Address City Name:
TITUSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32780-8627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-269-5533
Provider Business Mailing Address Fax Number:
321-269-3009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 S WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 24
Provider Business Practice Location Address City Name:
TITUSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32780-8627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-269-5533
Provider Business Practice Location Address Fax Number:
321-269-3009
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BORGES
Authorized Official First Name:
IBEM
Authorized Official Middle Name:
ROANDLO
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
321-269-5533

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  ME84507 , 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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