Provider Demographics
NPI:1194889709
Name:BAY AREA NEURO CLINIC INC
Entity type:Organization
Organization Name:BAY AREA NEURO CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:VICENTE
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSE MASSAGE THER
Authorized Official - Phone:813-985-3773
Mailing Address - Street 1:6275 E FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617
Mailing Address - Country:US
Mailing Address - Phone:813-985-3773
Mailing Address - Fax:813-984-7171
Practice Address - Street 1:6275 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617
Practice Address - Country:US
Practice Address - Phone:813-985-3773
Practice Address - Fax:813-984-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC5112OtherBCBS