Provider Demographics
NPI:1124424643
Name:EAST COAST NEURO LLC
Entity type:Organization
Organization Name:EAST COAST NEURO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:JACLYN
Authorized Official - Last Name:WILCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-513-3954
Mailing Address - Street 1:PO BOX 936957
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6957
Mailing Address - Country:US
Mailing Address - Phone:941-209-5410
Mailing Address - Fax:941-209-5652
Practice Address - Street 1:10550 DEERWOOD PARK BLVD STE 609A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-2811
Practice Address - Country:US
Practice Address - Phone:904-513-3954
Practice Address - Fax:904-212-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty