Healthcare Provider Details

I. General information

NPI: 1619439320
Provider Name (Legal Business Name): CERTIFIED SPINE AND PAIN CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9325 GLADES RD STE 104
BOCA RATON FL
33434-3988
US

IV. Provider business mailing address

1049 S STATE ROAD 7
WELLINGTON FL
33414-6135
US

V. Phone/Fax

Practice location:
  • Phone: 561-575-4582
  • Fax:
Mailing address:
  • Phone: 561-537-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JORGE GARCIA
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 561-578-4582