Provider Demographics
NPI:1336687391
Name:INTERVENTIONAL PAIN REHAB AND REGENERATIVE CENTER OF FLORIDA
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN REHAB AND REGENERATIVE CENTER OF FLORIDA
Other - Org Name:ANTI-AGING, REGENERATION AND PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:TATAW
Authorized Official - Last Name:BESONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-747-9771
Mailing Address - Street 1:2111 HONTOON RD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-4308
Mailing Address - Country:US
Mailing Address - Phone:386-747-9771
Mailing Address - Fax:
Practice Address - Street 1:2275 N VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-2833
Practice Address - Country:US
Practice Address - Phone:386-774-0109
Practice Address - Fax:386-774-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123086207Q00000X
FLME92729207V00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty