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General NPI Number Information
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NPI Number | 1114153483
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Entity Type | Organization
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Legal Business Name | SUNLAKE PAIN MANAGEMENT, LLC
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Dates
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Enumeration Date | 06/01/2009
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Last Update Date | 04/01/2010
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Provider Practice Location Address
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Address Line | 18964 DALE MABRY HWY N STE 101
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City | LUTZ
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State | FL
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Zip | 33548-4913
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Country | US
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Telephone | 813-948-2107
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Fax | 813-948-2790
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Provider Business Mailing Address
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Address Line | 18964 DALE MABRY HWY N STE 101
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City | LUTZ
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State | FL
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Zip | 33548-4913
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Country | US
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Telephone | 813-948-2107
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Fax | 813-948-2790
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. LUIS A. LOGRONO
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Credential | MD
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Telephone | 813-948-2107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | HCC8458
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License Number State | FL
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