Provider Demographics
NPI:1417082454
Name:SERVICE PAIN HEALING LABRA INC
Entity Type:Organization
Organization Name:SERVICE PAIN HEALING LABRA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:LABRADOR
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-584-0316
Mailing Address - Street 1:230 S DIXIE HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-4154
Mailing Address - Country:US
Mailing Address - Phone:561-584-0315
Mailing Address - Fax:305-675-2668
Practice Address - Street 1:230 S DIXIE HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-4154
Practice Address - Country:US
Practice Address - Phone:561-584-0315
Practice Address - Fax:305-675-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7523261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC7523OtherAHCA