MEDICARE: CHRONIC PAIN MANAGEMENT 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	ME71405	FL

General Provider Information

NPI Number	:	1952587172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRONIC PAIN MANAGEMENT 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	:	1660 BLANDING BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-1835
Country	:	US
Telephone Number	:	904-389-3800
Fax Number	:

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

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

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