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General NPI Number Information
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NPI Number | 1942868377
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Entity Type | Organization
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Legal Business Name | PAIN SPINE & WELLNESS LLC
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Dates
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Enumeration Date | 05/31/2019
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 9770 OLD BAYMEADOWS RD STE 141
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City | JACKSONVILLE
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State | FL
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Zip | 32256-7986
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Country | US
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Telephone | 904-944-2124
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Fax | 888-241-3383
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Provider Business Mailing Address
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Address Line | 10689 TOWN VIEW DR
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City | JACKSONVILLE
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State | FL
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Zip | 32256-4026
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Country | US
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Telephone | 904-944-2124
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Fax | 888-241-3383
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Authorized Official
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Title or Position | PRESIDENT
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Name | SOURIAL MORRIS SOURIAL
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Credential | DO
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Telephone | 904-944-2124
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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