Healthcare Provider Details

I. General information

NPI: 1750399200
Provider Name (Legal Business Name): TAMPA PAIN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 E FLETCHER AVE ROOM 204
TAMPA FL
33613-4708
US

IV. Provider business mailing address

3500 E FLETCHER AVE ROOM 204
TAMPA FL
33613-4708
US

V. Phone/Fax

Practice location:
  • Phone: 813-769-5629
  • Fax: 813-978-8797
Mailing address:
  • Phone: 813-769-5629
  • Fax: 813-978-8797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME58829
License Number StateFL

VIII. Authorized Official

Name: DAVID VANDERCAR
Title or Position: OWNER
Credential: MD
Phone: 813-769-5629