Provider Demographics
NPI:1528242906
Name:FLORIDA NEUROLOGICAL CENTER LLC
Entity type:Organization
Organization Name:FLORIDA NEUROLOGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-867-9877
Mailing Address - Street 1:2237 SW 19TH AVE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6505
Mailing Address - Country:US
Mailing Address - Phone:352-867-9877
Mailing Address - Fax:352-867-1040
Practice Address - Street 1:2237 SW 19TH AVENUE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7751
Practice Address - Country:US
Practice Address - Phone:352-867-9877
Practice Address - Fax:352-867-1040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA NEUROLOGICAL CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-20
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7448174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5751Medicare PIN