Basic Information
| Provider Information | |||||||||
| NPI: | 1689049900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CERTIFIED SPINE AND PAIN CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1049 S STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543769281 | ||||||||
| FaxNumber: | 5618282377 | ||||||||
| Practice Location | |||||||||
| Address1: | 1049 S STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615784582 | ||||||||
| FaxNumber: | 5618282377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2015 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | MALDONADO | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9543769281 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.