Healthcare Provider Details

I. General information

NPI: 1053183111
Provider Name (Legal Business Name): PREMIER PAIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9050 PINES BLVD STE 301
PEMBROKE PINES FL
33024-6422
US

IV. Provider business mailing address

9050 PINES BLVD STE 301
PEMBROKE PINES FL
33024-6422
US

V. Phone/Fax

Practice location:
  • Phone: 754-888-9080
  • Fax: 754-888-9280
Mailing address:
  • Phone: 754-888-9080
  • Fax: 754-888-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NINEDTY CORDOVA
Title or Position: OWNER
Credential: APRN
Phone: 754-888-9080