Provider Demographics
NPI:1265698963
Name:PAIN CARE PLACE
Entity type:Organization
Organization Name:PAIN CARE PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LOVERY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-654-2728
Mailing Address - Street 1:505 S. DILLARD
Mailing Address - Street 2:
Mailing Address - City:WINTER
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4651
Mailing Address - Country:US
Mailing Address - Phone:407-654-7276
Mailing Address - Fax:
Practice Address - Street 1:505 S. DILLARD
Practice Address - Street 2:
Practice Address - City:WINTER
Practice Address - State:FL
Practice Address - Zip Code:34787-4651
Practice Address - Country:US
Practice Address - Phone:407-654-7276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12701305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service