Provider Demographics
NPI:1033357694
Name:COAST PAIN RELIEF CENTER
Entity Type:Organization
Organization Name:COAST PAIN RELIEF CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-873-5552
Mailing Address - Street 1:3233 SW PORT ST. LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3490
Mailing Address - Country:US
Mailing Address - Phone:772-873-5552
Mailing Address - Fax:772-873-5747
Practice Address - Street 1:3233 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3490
Practice Address - Country:US
Practice Address - Phone:772-873-5552
Practice Address - Fax:772-873-5747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 62002261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty