Healthcare Provider Details

I. General information

NPI: 1689852493
Provider Name (Legal Business Name): SPORTS & INTERVENTIONAL PAIN MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8140 PICTON WAY SUITE 101
TRINITY FL
34655-1792
US

IV. Provider business mailing address

PO BOX 340287
TAMPA FL
33694-0287
US

V. Phone/Fax

Practice location:
  • Phone: 727-359-2552
  • Fax: 727-372-0402
Mailing address:
  • Phone: 727-359-2552
  • Fax: 727-372-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS9263
License Number StateFL

VIII. Authorized Official

Name: DR. EATON I YEN
Title or Position: EXECUTIVE
Credential: D.O.
Phone: 727-359-2552