Provider Demographics
NPI:1053631382
Name:FLA PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:FLA PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BODO
Authorized Official - Middle Name:
Authorized Official - Last Name:PYKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-622-7640
Mailing Address - Street 1:279 DOUGLAS AVE
Mailing Address - Street 2:SUITE 1108
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3324
Mailing Address - Country:US
Mailing Address - Phone:407-622-7640
Mailing Address - Fax:407-622-7644
Practice Address - Street 1:279 DOUGLAS AVE
Practice Address - Street 2:SUITE 1108
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3324
Practice Address - Country:US
Practice Address - Phone:407-622-7640
Practice Address - Fax:407-622-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS1683208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty