Basic Information
| Provider Information | |||||||||
| NPI: | 1093862062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 864164 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328864164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 DUNDEE RD | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338841166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VILLARREAL | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MBR | ||||||||
| AuthorizedOfficialTelephone: | 8632991231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | ME0054730 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.