Provider Demographics
NPI:1649354275
Name:PAIN CENTER OF ORLANDO
Entity type:Organization
Organization Name:PAIN CENTER OF ORLANDO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:225 W STATE RD 434 205
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 W STATE RD 434 205
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32750
Practice Address - Country:US
Practice Address - Phone:407-679-3337
Practice Address - Fax:407-678-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81513332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1011181OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL2000328Medicaid
FL2000328Medicaid