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General NPI Number Information
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NPI Number | 1245408830
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Entity Type | Organization
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Legal Business Name | COASTAL PAIN MANAGEMENT POMPANO DISPENSARY
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Dates
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Enumeration Date | 02/15/2008
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Last Update Date | 02/15/2008
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Provider Practice Location Address
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Address Line | 2301 W SAMPLE RD SUITE 7A
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City | POMPANO BEACH
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State | FL
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Zip | 33073-3081
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Country | US
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Telephone | 954-935-6063
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Fax |
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Provider Business Mailing Address
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Address Line | 2301 W SAMPLE RD SUITE 7A
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City | POMPANO BEACH
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State | FL
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Zip | 33073-3081
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Country | US
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Telephone | 954-935-6063
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE ADMIN.
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Name | CICELY D EASON
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Credential |
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Telephone | 954-935-6063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | ME57886
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License Number State | FL
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