Healthcare Provider Details

I. General information

NPI: 1093038937
Provider Name (Legal Business Name): PEARL MEDICAL PAIN CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2010
Last Update Date: 03/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 JACKSON AVE
SATELLITE BEACH FL
32937-2993
US

IV. Provider business mailing address

155 JACKSON AVE
SATELLITE BEACH FL
32937-2993
US

V. Phone/Fax

Practice location:
  • Phone: 321-773-2663
  • Fax:
Mailing address:
  • Phone: 321-773-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME36928
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH3794
License Number StateFL

VIII. Authorized Official

Name: MICHAEL VILLE
Title or Position: PRESIDENT
Credential: DC
Phone: 321-773-2663