MEDICARE: PURA VIDA PAIN CENTER, INC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MM18936	OTHER	FL	MASSAGE EST LICENSE

General Provider Information

NPI Number	:	1902013261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURA VIDA PAIN CENTER, INC

Provider Business Mailing Address
First Line	:	4801 E BUSCH BLVD
Second Line	:	UNIT A
City	:	TAMPA
State	:	FL
Zip	:	33617-6416
Country	:	US
Telephone Number	:	813-980-6700
Fax Number	:	813-980-6711

Provider Business Practice Location Address
First Line	:	4801 E BUSCH BLVD
Second Line	:	UNIT A
City	:	TAMPA
State	:	FL
Zip	:	33617-6416
Country	:	US
Telephone Number	:	813-980-6700
Fax Number	:	813-980-6711

Authorized Official
Title or Position	:	OWNER
Name	:	CHIARA WILLIAMS
Credential	:
Telephone Number	:	813-980-6700

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/22/2020

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