Provider Demographics
NPI:1700988672
Name:PAIN DIAGNOSTIC & MANAGEMENT CENTER LLC
Entity Type:Organization
Organization Name:PAIN DIAGNOSTIC & MANAGEMENT CENTER LLC
Other - Org Name:PAIN DIAGNOSTIC & MANAGEMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING REP
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:E
Authorized Official - Last Name:VENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-685-2191
Mailing Address - Street 1:321 E ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5253
Mailing Address - Country:US
Mailing Address - Phone:813-685-2191
Mailing Address - Fax:813-689-8755
Practice Address - Street 1:537 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3054
Practice Address - Country:US
Practice Address - Phone:863-293-3656
Practice Address - Fax:863-293-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593467412OtherTAX ID