Provider Demographics
NPI:1134598279
Name:TAMPA PAIN RELIEF CENTER, INC.
Entity type:Organization
Organization Name:TAMPA PAIN RELIEF CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-755-0693
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:727-755-0693
Mailing Address - Fax:727-755-0679
Practice Address - Street 1:403 S KINGS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5905
Practice Address - Country:US
Practice Address - Phone:727-755-0693
Practice Address - Fax:727-755-0679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89547332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262580600Medicaid
FL262580600Medicaid