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General NPI Number Information
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NPI Number | 1841328002
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Entity Type | Organization
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Legal Business Name | SPACE COAST PAIN RELIEF INC.
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3550 S WASHINGTON AVE SUITE 24
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City | TITUSVILLE
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State | FL
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Zip | 32780-8627
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Country | US
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Telephone | 321-269-5533
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Fax | 321-269-3009
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Provider Business Mailing Address
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Address Line | 3550 S WASHINGTON AVE SUITE 24
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City | TITUSVILLE
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State | FL
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Zip | 32780-8627
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Country | US
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Telephone | 321-269-5533
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Fax | 321-269-3009
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | IBEM ROANDLO BORGES
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Credential | M.D.
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Telephone | 321-269-5533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | ME84507
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License Number State | FL
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