Provider Demographics
NPI:1457650939
Name:PHYSICAL MEDICINE CENTER OF DEBARY
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE CENTER OF DEBARY
Other - Org Name:CENTRAL FLORIDA PAIN MANAGEMENT CENTERS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:NOEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MADERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-668-9999
Mailing Address - Street 1:2955 ENTERPRISE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2711
Mailing Address - Country:US
Mailing Address - Phone:386-668-9999
Mailing Address - Fax:386-668-0709
Practice Address - Street 1:2955 ENTERPRISE RD
Practice Address - Street 2:SUITE C
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2711
Practice Address - Country:US
Practice Address - Phone:386-668-9999
Practice Address - Fax:386-668-0709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL FLORIDA PAIN MANAGEMENT CENTERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-23
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME07230174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty