Provider Demographics
NPI:1073735577
Name:SOUTH MAIN PAIN, INC.
Entity Type:Organization
Organization Name:SOUTH MAIN PAIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIDKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-432-6021
Mailing Address - Street 1:7024 CHARLESTON SHORES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467
Mailing Address - Country:US
Mailing Address - Phone:561-432-6021
Mailing Address - Fax:
Practice Address - Street 1:607 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430
Practice Address - Country:US
Practice Address - Phone:561-996-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty