Provider Demographics
NPI:1104538255
Name:NEUROLOGY HEADACHE ASSOCIATES, LLC
Entity type:Organization
Organization Name:NEUROLOGY HEADACHE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:F
Authorized Official - Last Name:STAKEBAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:801-603-8002
Mailing Address - Street 1:6500 N SOCRUM LOOP RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4179
Mailing Address - Country:US
Mailing Address - Phone:863-853-3331
Mailing Address - Fax:
Practice Address - Street 1:6500 N SOCRUM LOOP RD STE 200
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4179
Practice Address - Country:US
Practice Address - Phone:863-853-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty