Provider Demographics
NPI:1558573188
Name:CENTRAL FLORIDA PAIN & SPINE INSTITUTE P A
Entity Type:Organization
Organization Name:CENTRAL FLORIDA PAIN & SPINE INSTITUTE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-274-0097
Mailing Address - Street 1:PO BOX 731618
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-1618
Mailing Address - Country:US
Mailing Address - Phone:386-274-0097
Mailing Address - Fax:386-274-4996
Practice Address - Street 1:725 W GRANADA BLVD
Practice Address - Street 2:UNIT #22
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5107
Practice Address - Country:US
Practice Address - Phone:386-274-0097
Practice Address - Fax:386-274-4996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86188261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578507893OtherINDIVIDUAL NPI NUMBER
FLME86188OtherFL MEDICAL LIC #
FLME86188OtherFL MEDICAL LIC #
FLME86188OtherFL MEDICAL LIC #
H86402Medicare UPIN