Healthcare Provider Details

I. General information

NPI: 1942868377
Provider Name (Legal Business Name): PAIN SPINE & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9770 OLD BAYMEADOWS RD STE 141
JACKSONVILLE FL
32256-7986
US

IV. Provider business mailing address

10689 TOWN VIEW DR
JACKSONVILLE FL
32256-4026
US

V. Phone/Fax

Practice location:
  • Phone: 904-944-2124
  • Fax: 888-241-3383
Mailing address:
  • Phone: 904-944-2124
  • Fax: 888-241-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SOURIAL MORRIS SOURIAL
Title or Position: PRESIDENT
Credential: DO
Phone: 904-944-2124