Healthcare Provider Details

I. General information

NPI: 1912367426
Provider Name (Legal Business Name): PAIN MANAGEMENT CLINICS OF FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3308 NE 34TH ST
FORT LAUDERDALE FL
33308-6906
US

IV. Provider business mailing address

11555 HERON BAY BLVD SUITE 200
CORAL SPRINGS FL
33076-3360
US

V. Phone/Fax

Practice location:
  • Phone: 954-564-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberOS9686
License Number StateFL

VIII. Authorized Official

Name: MICHAEL S LANDRY
Title or Position: MANAGING PARTNER
Credential:
Phone: 786-233-8722