1043765753 NPI number — NEUROLOGY RESTORATION CENTER LLC

Table of content: (NPI 1043765753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043765753 NPI number — NEUROLOGY RESTORATION CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGY RESTORATION CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEUROLOGY RESTORATION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043765753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7938
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT SAINT LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34985-7938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-210-1162
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 SE HILLMOOR DR
Provider Second Line Business Practice Location Address:
SUITE D-16
Provider Business Practice Location Address City Name:
PORT SAINT LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-7552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-201-1162
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VAZQUEZ
Authorized Official First Name:
LUZ
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
772-210-1162

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  ME68140 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 257198600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 019519900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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