Provider Demographics
NPI:1043765753
Name:NEUROLOGY RESTORATION CENTER LLC
Entity Type:Organization
Organization Name:NEUROLOGY RESTORATION CENTER LLC
Other - Org Name:NEUROLOGY RESTORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:MS
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:G
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-210-1162
Mailing Address - Street 1:PO BOX 7938
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-7938
Mailing Address - Country:US
Mailing Address - Phone:772-210-1162
Mailing Address - Fax:
Practice Address - Street 1:1701 SE HILLMOOR DR
Practice Address - Street 2:SUITE D-16
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7552
Practice Address - Country:US
Practice Address - Phone:772-201-1162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME681402084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257198600Medicaid
FL319132Medicare UPIN