Provider Demographics
NPI:1578224135
Name:FORMOSO PAIN SPECIALISTS, PA
Entity Type:Organization
Organization Name:FORMOSO PAIN SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FERDINAND
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FORMOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-588-2393
Mailing Address - Street 1:11555 CENTRAL PKWY STE 304
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2694
Mailing Address - Country:US
Mailing Address - Phone:904-650-2963
Mailing Address - Fax:
Practice Address - Street 1:11555 CENTRAL PKWY STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2694
Practice Address - Country:US
Practice Address - Phone:904-650-2963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain