Provider Demographics
NPI:1790387702
Name:GROWING PAIN LLC
Entity Type:Organization
Organization Name:GROWING PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-585-2662
Mailing Address - Street 1:1488 LAGONI CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-1890
Mailing Address - Country:US
Mailing Address - Phone:386-585-2662
Mailing Address - Fax:386-200-6110
Practice Address - Street 1:1488 LAGONI CIR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-1890
Practice Address - Country:US
Practice Address - Phone:386-585-2662
Practice Address - Fax:386-200-6110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102122700Medicaid