Provider Demographics
NPI:1720383425
Name:FLORIDA PAIN CARE AND REHAB CORP
Entity Type:Organization
Organization Name:FLORIDA PAIN CARE AND REHAB CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-482-3838
Mailing Address - Street 1:1456 S SEMORAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-2918
Mailing Address - Country:US
Mailing Address - Phone:407-482-3838
Mailing Address - Fax:407-382-4095
Practice Address - Street 1:1456 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-2918
Practice Address - Country:US
Practice Address - Phone:407-482-3838
Practice Address - Fax:407-382-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5539111NR0400X
FLHCC8963261QH0100X
FLHCC 8963261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service