Provider Demographics
NPI:1093388217
Name:SPACE COAST SPINE AND PAIN INSTITUTE LLC
Entity Type:Organization
Organization Name:SPACE COAST SPINE AND PAIN INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-432-5480
Mailing Address - Street 1:285 LANSING ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-5102
Mailing Address - Country:US
Mailing Address - Phone:321-361-5619
Mailing Address - Fax:
Practice Address - Street 1:205 E NASA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1954
Practice Address - Country:US
Practice Address - Phone:321-361-5619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-24
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty