Basic Information
| Provider Information | |||||||||
| NPI: | 1760852776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAMPA PAIN RELIEF CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4919 MEMORIAL HWY STE 200 | ||||||||
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| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336347500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135696500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 MEDICAL PARK DR STE 510 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336136602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135696500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | BALDOCK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | BOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER AND AUTHROIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152345900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | FL | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 262580601 | 05 | FL | MEDICAID |