Healthcare Provider Details

I. General information

NPI: 1023195658
Provider Name (Legal Business Name): PAN AMERICAN PAIN INSTITUTE PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16542 N DALE MABRY HWY
TAMPA FL
33618-1325
US

IV. Provider business mailing address

PO BOX 20286
TAMPA FL
33622-0286
US

V. Phone/Fax

Practice location:
  • Phone: 813-908-7868
  • Fax:
Mailing address:
  • Phone: 727-823-2188
  • Fax: 727-823-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME79046
License Number StateFL

VIII. Authorized Official

Name: DARIO AQUILES GRISALES
Title or Position: OWNER PROVIDER
Credential: MD
Phone: 813-908-7868