Provider Demographics
NPI:1578872602
Name:PAIN CARE MANAGEMENT OF MELBOURNE, LLC
Entity Type:Organization
Organization Name:PAIN CARE MANAGEMENT OF MELBOURNE, LLC
Other - Org Name:ATLANTIS PAIN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:C
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-251-4462
Mailing Address - Street 1:5036 DR PHILLIPS BLVD
Mailing Address - Street 2:SUITE 337
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-3310
Mailing Address - Country:US
Mailing Address - Phone:321-251-4462
Mailing Address - Fax:888-469-1872
Practice Address - Street 1:3150 N WICKHAM RD
Practice Address - Street 2:SUITE 9
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2322
Practice Address - Country:US
Practice Address - Phone:321-773-4134
Practice Address - Fax:321-574-5611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMC1568261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain