Provider Demographics
NPI:1942512447
Name:PROFESSIONAL PAIN MANAGEMENT CLINIC INC
Entity Type:Organization
Organization Name:PROFESSIONAL PAIN MANAGEMENT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EREZ
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-584-7009
Mailing Address - Street 1:3267 DAVIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312
Mailing Address - Country:US
Mailing Address - Phone:954-584-7009
Mailing Address - Fax:954-584-7209
Practice Address - Street 1:3267 DAVIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312
Practice Address - Country:US
Practice Address - Phone:954-584-7009
Practice Address - Fax:954-584-7209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4663208D00000X
261Q00000X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty