Basic Information
| Provider Information | |||||||||
| NPI: | 1447863204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CERTIFIED SPINE AND PAIN CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11211 PROSPERITY FARMS RD STE B104 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334103453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615374526 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 S MAIN ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334304910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615784582 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | MALDONADO | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5615784562 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.