Provider Demographics
NPI:1528277670
Name:PORT ST LUCIE PAIN MANAGEMENT PLLC
Entity type:Organization
Organization Name:PORT ST LUCIE PAIN MANAGEMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-335-7246
Mailing Address - Street 1:8235 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2848
Mailing Address - Country:US
Mailing Address - Phone:772-335-7246
Mailing Address - Fax:
Practice Address - Street 1:8235 SOUTH US HWY 1
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-335-7246
Practice Address - Fax:772-335-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15198AOtherMEDICARE ID
FLE32589OtherUPIN
10719333OtherCAQH