Healthcare Provider Details

I. General information

NPI: 1073918371
Provider Name (Legal Business Name): PAIN AND SPINE PHYSIO REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTHPARK BLVD SUITE 408 B
ST AUGUSTINE FL
32086-5189
US

IV. Provider business mailing address

100 SOUTHPARK BLVD SUITE 408-B
ST AUGUSTINE FL
32086-5189
US

V. Phone/Fax

Practice location:
  • Phone: 518-407-3422
  • Fax:
Mailing address:
  • Phone: 518-407-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT7862
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberPT0007862
License Number StateFL

VIII. Authorized Official

Name: MR. REGINO IRWIN B REYES
Title or Position: AMBR
Credential: PT
Phone: 518-407-3422