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General NPI Number Information
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NPI Number | 1801346184
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Entity Type | Organization
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Legal Business Name | FLORIDA SPINE AND PAIN, LLC
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Dates
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Enumeration Date | 10/10/2016
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Last Update Date | 03/04/2017
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Provider Practice Location Address
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Address Line | 1400 N US HWY 441 STE 536
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City | LADY LAKE
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State | FL
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Zip | 32159-8986
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Country | US
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Telephone | 352-775-2826
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Fax | 352-547-4011
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Provider Business Mailing Address
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Address Line | 1400 N US HWY 441 STE 536
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City | LADY LAKE
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State | FL
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Zip | 32159-8986
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Country | US
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Telephone | 352-775-2826
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Fax | 352-547-4011
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Authorized Official
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Title or Position | CEO
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Name | VIJAY GUTTI BABU
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Credential | M.D.
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Telephone | 352-775-2826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | ME126127
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License Number State | FL
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