Basic Information
| Provider Information | |||||||||
| NPI: | 1942743554 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CERTIFIED SPINE AND PAIN CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1049 S STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615784582 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 S FEDERAL HWY STE 611 | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330627518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615784582 | ||||||||
| FaxNumber: | 5614324843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2016 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | MALDONADO | ||||||||
| AuthorizedOfficialFirstName: | EDWIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5615784582 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.