Healthcare Provider Details

I. General information

NPI: 1477134658
Provider Name (Legal Business Name): FLORIDA INTERVENTIONAL PROVIDERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 SE 23RD RD
HOMESTEAD FL
33035-1904
US

IV. Provider business mailing address

2202 SE 23RD RD
HOMESTEAD FL
33035-1904
US

V. Phone/Fax

Practice location:
  • Phone: 201-951-3113
  • Fax: 305-675-3346
Mailing address:
  • Phone: 201-951-3113
  • Fax: 305-675-3346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DARRELL JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 561-356-6313