MEDICARE: INNOVATIVE PHYSIATRY SPINE CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	OS12124	FL

General Provider Information

NPI Number	:	1487175881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PHYSIATRY SPINE CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 385
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32004-0385
Country	:	US
Telephone Number	:	904-671-0288
Fax Number	:	904-508-0674

Provider Business Practice Location Address
First Line	:	165 DURBIN STATION CT STE 601
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-9370
Country	:	US
Telephone Number	:	904-671-0288
Fax Number	:	904-508-0674

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	SECK LIM
Credential	:
Telephone Number	:	904-671-0288

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	09/02/2021

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