Healthcare Provider Details

I. General information

NPI: 1831850494
Provider Name (Legal Business Name): FORMOSO PAIN SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 13TH AVE S STE 170
JACKSONVILLE BEACH FL
32250-3235
US

IV. Provider business mailing address

11555 CENTRAL PKWY STE 304
JACKSONVILLE FL
32224-2694
US

V. Phone/Fax

Practice location:
  • Phone: 904-650-2963
  • Fax:
Mailing address:
  • Phone: 904-650-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FERDINAND JOSEPH FORMOSO
Title or Position: OWNER
Credential:
Phone: 904-588-2393