MEDICARE: FULL SERVICE PAIN MANAGEMENT

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	261QP3300X	Pain Clinic/Center	PMC541	FL

General Provider Information

NPI Number	:	1679883656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL SERVICE PAIN MANAGEMENT

Provider Business Mailing Address
First Line	:	3107 W. HALLANDALE BEACH BLVD
Second Line	:	SUITE #102
City	:	PEMBROKE PARK
State	:	FL
Zip	:	33009-5144
Country	:	US
Telephone Number	:	954-987-6100
Fax Number	:	954-987-2360

Provider Business Practice Location Address
First Line	:	3107 W. HALLANDALE BEACH BLVD
Second Line	:	SUITE #102
City	:	PEMBROKE PARK
State	:	FL
Zip	:	33009-5144
Country	:	US
Telephone Number	:	954-987-6100
Fax Number	:	954-987-2360

Authorized Official
Title or Position	:	VP
Name	:	EDUARDO MILA PRATS
Credential	:	MD
Telephone Number	:	954-987-6100

Provider Enumeration Date	:	10/08/2010
Last Update Date	:	10/08/2010

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Directions to “FULL SERVICE PAIN MANAGEMENT ” Practice Location

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