Provider Demographics
NPI:1457591828
Name:MEDICINE MAN PAIN MANAGEMENT CENTER
Entity Type:Organization
Organization Name:MEDICINE MAN PAIN MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:SEZHI
Authorized Official - Last Name:YUAN
Authorized Official - Suffix:
Authorized Official - Credentials:AP
Authorized Official - Phone:786-573-4777
Mailing Address - Street 1:14471 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-7924
Mailing Address - Country:US
Mailing Address - Phone:786-573-4777
Mailing Address - Fax:786-573-4887
Practice Address - Street 1:14471 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7924
Practice Address - Country:US
Practice Address - Phone:786-573-4777
Practice Address - Fax:786-573-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 1607261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP 1607OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH MEDICAL LICENSE