Provider Demographics
NPI:1073830170
Name:NEUROLOGY ASSOCIATES OF BREVARD LLC
Entity Type:Organization
Organization Name:NEUROLOGY ASSOCIATES OF BREVARD LLC
Other - Org Name:NEUROLOGY ASSOCIATES OF BREVARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MSO CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-449-4168
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3488
Mailing Address - Country:US
Mailing Address - Phone:321-449-4168
Mailing Address - Fax:321-449-4164
Practice Address - Street 1:8055 SPYGLASS HILL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8564
Practice Address - Country:US
Practice Address - Phone:321-637-4760
Practice Address - Fax:321-637-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114197423OtherDR NPI