Provider Demographics
NPI:1629671383
Name:FLORIDA EEG LLC
Entity Type:Organization
Organization Name:FLORIDA EEG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLESTERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-408-2445
Mailing Address - Street 1:117 N KIRKMAN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-1403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 N KIRKMAN RD STE 3
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-1403
Practice Address - Country:US
Practice Address - Phone:407-408-2445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No293D00000XLaboratoriesPhysiological Laboratory