Healthcare Provider Details

I. General information

NPI: 1780962027
Provider Name (Legal Business Name): FLORIDA PAIN & WELLNESS CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5243 E COLONIAL DR
ORLANDO FL
32807-1895
US

IV. Provider business mailing address

PO BOX 140038
ORLANDO FL
32814-0038
US

V. Phone/Fax

Practice location:
  • Phone: 407-275-9335
  • Fax: 407-275-9991
Mailing address:
  • Phone: 407-275-9335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
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: DR. RANDALL WILDS
Title or Position: OWNER
Credential: DC
Phone: 407-275-9335