Healthcare Provider Details

I. General information

NPI: 1104472414
Provider Name (Legal Business Name): SPINE CENTER OF FL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7964 SUMMERLIN LAKES DR
FORT MYERS FL
33907-1816
US

IV. Provider business mailing address

11921 ROCKVILLE PIKE STE 505
ROCKVILLE MD
20852-2758
US

V. Phone/Fax

Practice location:
  • Phone: 301-945-5111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EUGENE D. MAHANEY
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: MD
Phone: 313-593-5000