Healthcare Provider Details

I. General information

NPI: 1598990152
Provider Name (Legal Business Name): SWCN PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1564 KINGSLEY AVE
ORANGE PARK FL
32073-4511
US

IV. Provider business mailing address

PO BOX 864483
ORLANDO FL
32886-4483
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-0400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CARL R NOBACK
Title or Position: MEMBER
Credential: MD
Phone: 941-360-1566