Provider Demographics
NPI:1104005859
Name:ADVANCED PAIN MANAGEMENT SPECIALIST
Entity Type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-437-8000
Mailing Address - Street 1:PO BOX 07400
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-0400
Mailing Address - Country:US
Mailing Address - Phone:239-437-8000
Mailing Address - Fax:
Practice Address - Street 1:6120 WINKLER RD
Practice Address - Street 2:SUITE J
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8125
Practice Address - Country:US
Practice Address - Phone:239-437-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBD1688641332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site