License Number: ME118157Data As Of 12/5/2023
|License Expiration Date||1/31/2026|
|License Original Issue Date||11/26/2013|
|Address of Record||1350 S Hickory Street|
|MELBOURNE, FL 32901|
|Controlled Substance Prescriber (for the Treatment of Chronic Non-malignant Pain)||No|
|Discipline on File||Yes|
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