Provider Demographics
NPI:1114786001
Name:PORT ST LUCIE PAIN MANAGEMENT SPECIALISTS
Entity Type:Organization
Organization Name:PORT ST LUCIE PAIN MANAGEMENT SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-335-7246
Mailing Address - Street 1:8235 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2848
Mailing Address - Country:US
Mailing Address - Phone:772-335-7246
Mailing Address - Fax:772-335-7202
Practice Address - Street 1:8235 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2848
Practice Address - Country:US
Practice Address - Phone:772-335-7246
Practice Address - Fax:772-335-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty