MEDICARE: HURRICANE PAIN CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician
2	261QP3300X	Pain Clinic/Center	HCC9047	FL

General Provider Information

NPI Number	:	1043578511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HURRICANE PAIN CLINIC, LLC

Provider Business Mailing Address
First Line	:	391 LEE BLVD
Second Line	:	SUITE 200
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-4973
Country	:	US
Telephone Number	:	239-333-8618
Fax Number	:	239-277-0703

Provider Business Practice Location Address
First Line	:	391 LEE BLVD
Second Line	:	SUITE 200
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-4973
Country	:	US
Telephone Number	:	239-333-8618
Fax Number	:	239-277-0703

Authorized Official
Title or Position	:	C.E.O. / OWNER
Name	:	BRIAN R RUSH
Credential	:
Telephone Number	:	239-333-8618

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	09/19/2014

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