1386190734 NPI number — BRAIN SPINE AND SLEEP INSTITUTE LLC

Table of content: (NPI 1386190734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386190734 NPI number — BRAIN SPINE AND SLEEP INSTITUTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAIN SPINE AND SLEEP INSTITUTE 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:
BRAIN SPINE AND SLEEP INSTITUTE
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:
1386190734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 CARLTON AVE
Provider Second Line Business Mailing Address:
SUITE 1300
Provider Business Mailing Address City Name:
LAKE WALES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33853-4347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-676-6386
Provider Business Mailing Address Fax Number:
863-676-3124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 CARLTON AVE
Provider Second Line Business Practice Location Address:
SUITE 1300
Provider Business Practice Location Address City Name:
LAKE WALES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33853-4347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-676-6386
Provider Business Practice Location Address Fax Number:
863-676-3124
Provider Enumeration Date:
08/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MOUSLI
Authorized Official First Name:
HASAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
863-676-6386

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084S0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ME97722 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 018952500 . 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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