Provider Demographics
NPI:1578879375
Name:125TH STREET NM CORP
Entity Type:Organization
Organization Name:125TH STREET NM CORP
Other - Org Name:125TH STREET PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:NIZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-235-7240
Mailing Address - Street 1:505 NE 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-4718
Mailing Address - Country:US
Mailing Address - Phone:786-235-7240
Mailing Address - Fax:786-235-7241
Practice Address - Street 1:505 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-4718
Practice Address - Country:US
Practice Address - Phone:786-235-7240
Practice Address - Fax:786-235-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMC 20261QP2000X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy