Provider Demographics
NPI:1619921301
Name:TREASURE COAST NEUROLOGY WEST, LLC
Entity Type:Organization
Organization Name:TREASURE COAST NEUROLOGY WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VANDEVERE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:772-873-1005
Mailing Address - Street 1:PO BOX 881565
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-1565
Mailing Address - Country:US
Mailing Address - Phone:772-873-1005
Mailing Address - Fax:772-595-9986
Practice Address - Street 1:1420 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1709
Practice Address - Country:US
Practice Address - Phone:772-873-1005
Practice Address - Fax:772-595-9986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3283142261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty