Healthcare Provider Details

I. General information

NPI: 1093388217
Provider Name (Legal Business Name): SPACE COAST SPINE AND PAIN INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2021
Last Update Date: 07/24/2021
Certification Date: 07/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E NASA BLVD STE 200
MELBOURNE FL
32901-1954
US

IV. Provider business mailing address

285 LANSING ISLAND DR
INDIAN HARBOUR BEACH FL
32937-5102
US

V. Phone/Fax

Practice location:
  • Phone: 321-361-5619
  • Fax:
Mailing address:
  • Phone: 321-361-5619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: SONYA WARNICK
Title or Position: ADMINISTRATOR
Credential:
Phone: 321-432-5480