=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053631382
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLA PAIN MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2010
-----------------------------------------------------
Last Update Date | 06/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 279 DOUGLAS AVE SUITE 1108
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-622-7640
-----------------------------------------------------
Fax | 407-622-7644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 DOUGLAS AVE SUITE 1108
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-622-7640
-----------------------------------------------------
Fax | 407-622-7644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | MR. BODO PYKO
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 407-622-7640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | OS1683
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------