Provider Demographics
NPI:1902013261
Name:PURA VIDA PAIN CENTER, INC
Entity Type:Organization
Organization Name:PURA VIDA PAIN CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHIARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-980-6700
Mailing Address - Street 1:4801 E BUSCH BLVD
Mailing Address - Street 2:UNIT A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-6416
Mailing Address - Country:US
Mailing Address - Phone:813-980-6700
Mailing Address - Fax:813-980-6711
Practice Address - Street 1:4801 E BUSCH BLVD
Practice Address - Street 2:UNIT A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-6416
Practice Address - Country:US
Practice Address - Phone:813-980-6700
Practice Address - Fax:813-980-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMM18936OtherMASSAGE EST LICENSE