Healthcare Provider Details

I. General information

NPI: 1417082454
Provider Name (Legal Business Name): SERVICE PAIN HEALING LABRA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S DIXIE HWY SUITE 102
LAKE WORTH FL
33460-4154
US

IV. Provider business mailing address

230 S DIXIE HWY SUITE 102
LAKE WORTH FL
33460-4154
US

V. Phone/Fax

Practice location:
  • Phone: 561-584-0315
  • Fax: 305-675-2668
Mailing address:
  • Phone: 561-584-0315
  • Fax: 305-675-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberHCC7523
License Number StateFL

VIII. Authorized Official

Name: MR. OSVALDO LABRADOR LOPEZ
Title or Position: PRESIDENT
Credential:
Phone: 561-584-0316