Basic Information
| Provider Information | |||||||||
| NPI: | 1043358005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEUROLOGICAL CARE CENTER, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2736 UNIVERSITY BLVD W | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047334262 | ||||||||
| FaxNumber: | 9046365786 | ||||||||
| Practice Location | |||||||||
| Address1: | 2736 UNIVERSITY BLVD W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047334262 | ||||||||
| FaxNumber: | 9046365786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | GAMA | ||||||||
| AuthorizedOfficialFirstName: | CARLOS | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP PRACTICE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9047334262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0039492 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.