Healthcare Provider Details

I. General information

NPI: 1033357694
Provider Name (Legal Business Name): COAST PAIN RELIEF CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3233 SW PORT ST LUCIE BLVD
PORT ST LUCIE FL
34953-3490
US

IV. Provider business mailing address

3233 SW PORT ST. LUCIE BLVD
PORT ST. LUCIE FL
34953-3490
US

V. Phone/Fax

Practice location:
  • Phone: 772-873-5552
  • Fax: 772-873-5747
Mailing address:
  • Phone: 772-873-5552
  • Fax: 772-873-5747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME 62002
License Number StateFL

VIII. Authorized Official

Name: MS. LINDSAY NICOLE PETTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 772-873-5552