Healthcare Provider Details

I. General information

NPI: 1033121546
Provider Name (Legal Business Name): SOUTH LAKE PAIN INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 HOOKS STREET
CLERMONT FL
34711
US

IV. Provider business mailing address

2440 HOOKS STREET
CLERMONT FL
34711
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0833
  • Fax: 352-394-0367
Mailing address:
  • Phone: 352-394-0833
  • Fax: 352-394-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOS8836
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. SAMILDRE PACHECO
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 352-394-0833