=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619347309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE PAIN MANAGEMENT AND SPORTS MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2015
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3255 NW 94TH AVENUE # 9161
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-620-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3255 NW 94TH AVENUE # 9161
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-620-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGEMENT
-----------------------------------------------------
Name | JANICE VICTOR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 888-620-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | ME100973
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------