Healthcare Provider Details

I. General information

NPI: 1336687391
Provider Name (Legal Business Name): INTERVENTIONAL PAIN REHAB AND REGENERATIVE CENTER OF FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 N VOLUSIA AVE
ORANGE CITY FL
32763-2833
US

IV. Provider business mailing address

2111 HONTOON RD
DELAND FL
32720-4308
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-0109
  • Fax: 386-774-1203
Mailing address:
  • Phone: 386-747-9771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME123086
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME92729
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME92729
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME92729
License Number StateFL

VIII. Authorized Official

Name: DR. GEORGE TATAW BESONG
Title or Position: PRESIDENT & CEO
Credential: M.D
Phone: 386-747-9771