Provider Demographics
NPI:1023650595
Name:FL NEURO PAIN AND SPINE CENTER, .P.A.
Entity type:Organization
Organization Name:FL NEURO PAIN AND SPINE CENTER, .P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-215-3000
Mailing Address - Street 1:2614 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4311
Mailing Address - Country:US
Mailing Address - Phone:850-215-3000
Mailing Address - Fax:850-215-3150
Practice Address - Street 1:2614 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-215-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FL NEURO PAIN AND SPINE CENTER, .P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-16
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006J1OtherBLUE CROSS BLUE SHIELD