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General NPI Number Information
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NPI Number | 1316229982
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Entity Type | Organization
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Legal Business Name | THE VAIN CLINIC LLC
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Dates
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Enumeration Date | 09/09/2011
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Last Update Date | 09/09/2011
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Provider Practice Location Address
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Address Line | 160 NW CENTRAL PARK PLZ STE 104
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1825
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Country | US
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Telephone | 772-871-8922
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Fax |
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Provider Business Mailing Address
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Address Line | 160 NW CENTRAL PARK PLZ STE 104
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1825
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Country | US
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Telephone | 772-871-8922
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PAMELA ROBERTS
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Credential |
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Telephone | 772-871-8922
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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 | ME63493
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License Number State | FL
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