Provider Demographics
NPI:1619347309
Name:MOBILE PAIN MANAGEMENT AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:MOBILE PAIN MANAGEMENT AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-620-7246
Mailing Address - Street 1:3255 NW 94TH AVENUE
Mailing Address - Street 2:# 9161
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33075
Mailing Address - Country:US
Mailing Address - Phone:888-620-7246
Mailing Address - Fax:
Practice Address - Street 1:3255 NW 94TH AVENUE
Practice Address - Street 2:# 9161
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33075
Practice Address - Country:US
Practice Address - Phone:888-620-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100973208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty