Healthcare Provider Details

I. General information

NPI: 1679883656
Provider Name (Legal Business Name): FULL SERVICE PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3107 W. HALLANDALE BEACH BLVD SUITE #102
PEMBROKE PARK FL
33009-5144
US

IV. Provider business mailing address

3107 W. HALLANDALE BEACH BLVD SUITE #102
PEMBROKE PARK FL
33009-5144
US

V. Phone/Fax

Practice location:
  • Phone: 954-987-6100
  • Fax: 954-987-2360
Mailing address:
  • Phone: 954-987-6100
  • Fax: 954-987-2360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberPMC541
License Number StateFL

VIII. Authorized Official

Name: EDUARDO MILA PRATS
Title or Position: VP
Credential: MD
Phone: 954-987-6100