=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093993396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE PAIN CARE OF SOUTH FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2008
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2585 S STATE ROAD 7 STE 110
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-9438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-795-8655
-----------------------------------------------------
Fax | 561-795-8449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2585 S STATE ROAD 7 STE 110
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-9438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-795-8655
-----------------------------------------------------
Fax | 561-795-8449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | KINYATA SMART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-795-8655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME56226
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------