Provider Demographics
NPI:1760004501
Name:TREASURE COAST NEUROLOGY, INC
Entity Type:Organization
Organization Name:TREASURE COAST NEUROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NEUROLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:EDUARDO
Authorized Official - Last Name:MONTEJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-528-1310
Mailing Address - Street 1:2401 FRIST BLVD STE 2B
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4800
Mailing Address - Country:US
Mailing Address - Phone:772-528-1310
Mailing Address - Fax:
Practice Address - Street 1:2401 FRIST BLVD STE 2B
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4800
Practice Address - Country:US
Practice Address - Phone:772-528-1310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty