MEDICARE: COASTAL PAIN MANAGEMENT DELRAY DISPENSARY

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	332900000X	Non-Pharmacy Dispensing Site	ME62450	FL

General Provider Information

NPI Number	:	1629254818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL PAIN MANAGEMENT DELRAY DISPENSARY

Provider Business Mailing Address
First Line	:	PO BOX 4688
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33338-4688
Country	:	US
Telephone Number	:	954-376-7313
Fax Number	:	954-697-0153

Provider Business Practice Location Address
First Line	:	75 NE 6TH AVE
Second Line	:	SUITE #104
City	:	DELRAY BEACH
State	:	FL
Zip	:	33483-5435
Country	:	US
Telephone Number	:	561-272-3880
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE ADMINISTRATOR
Name	:	MS. CICELY D EASON
Credential	:
Telephone Number	:	561-789-4911

Provider Enumeration Date	:	01/17/2008
Last Update Date	:	05/07/2008

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