Provider Demographics
NPI:1013502285
Name:GULF COAST PMRA LLC
Entity Type:Organization
Organization Name:GULF COAST PMRA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MNAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-900-1326
Mailing Address - Street 1:PO BOX 61925
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-1925
Mailing Address - Country:US
Mailing Address - Phone:727-900-1326
Mailing Address - Fax:727-954-6546
Practice Address - Street 1:9369 GOLDEN RAIN LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-5136
Practice Address - Country:US
Practice Address - Phone:727-900-1326
Practice Address - Fax:727-954-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64098OtherFLORIDA BLUE