1467926006 NPI number — IDEAL NEUROLOGY CLINIC, PLLC

Table of content: (NPI 1467926006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467926006 NPI number — IDEAL NEUROLOGY CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL NEUROLOGY CLINIC, PLLC
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:
Provider Other Organization Name Type Code:
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:
1467926006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 880761
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33488-0761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-961-8575
Provider Business Mailing Address Fax Number:
561-898-1710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7000 W PALMETTO PARK RD STE 406
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33433-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-961-8575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CHALFIN
Authorized Official First Name:
RENATA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN OWNER/CEO/MEDICAL DIRECTO
Authorized Official Telephone Number:
561-961-8575

Provider Taxonomy Codes

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

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

  • Identifier: 105944300 . 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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