Healthcare Provider Details

I. General information

NPI: 1699018127
Provider Name (Legal Business Name): FLA MEDICAL PAIN RELIEF & DETOX CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6740 TAFT ST
HOLLYWOOD FL
33024-3903
US

IV. Provider business mailing address

6740 TAFT ST
HOLLYWOOD FL
33024-3903
US

V. Phone/Fax

Practice location:
  • Phone: 954-966-7911
  • Fax: 954-966-3352
Mailing address:
  • Phone: 954-966-7911
  • Fax: 954-966-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JANIS MIKUS
Title or Position: DIRECTOR
Credential:
Phone: 954-966-7911