=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326478942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW TAMPA INTERVENTIONAL PAIN AND SPORTS MEDICINE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2013
-----------------------------------------------------
Last Update Date | 12/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2014 ASHLEY OAKS CIR SUITE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-999-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2014 ASHLEY OAKS CIR SUITE 101
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-999-3030
-----------------------------------------------------
Fax | 813-991-7377
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSE DE LA TORRE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-309-1013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | ME89848
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | ME89848
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------