Healthcare Provider Details

I. General information

NPI: 1700988672
Provider Name (Legal Business Name): PAIN DIAGNOSTIC & MANAGEMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 E CENTRAL AVE
WINTER HAVEN FL
33880-3054
US

IV. Provider business mailing address

321 E ROBERTSON ST
BRANDON FL
33511-5253
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-3656
  • Fax: 863-293-7887
Mailing address:
  • Phone: 813-685-2191
  • Fax: 813-689-8755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PEGGY E VENT
Title or Position: BILLING REP
Credential:
Phone: 813-685-2191