Provider Demographics
NPI:1396163952
Name:NEUROPLACE P.A.
Entity type:Organization
Organization Name:NEUROPLACE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VESNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-370-3789
Mailing Address - Street 1:6290 BETTY AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4202
Mailing Address - Country:US
Mailing Address - Phone:321-301-4299
Mailing Address - Fax:321-301-4299
Practice Address - Street 1:6290 BETTY AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-4202
Practice Address - Country:US
Practice Address - Phone:321-301-4299
Practice Address - Fax:321-301-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104201261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002469900Medicaid
FL002469900Medicaid