=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558573188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL FLORIDA PAIN & SPINE INSTITUTE P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 W GRANADA BLVD UNIT #22
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-5107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-274-0097
-----------------------------------------------------
Fax | 386-274-4996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 731618
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32173-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-274-0097
-----------------------------------------------------
Fax | 386-274-4996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ROCHELLE R CANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-274-0097
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | ME86188
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------