Provider Demographics
NPI:1790008811
Name:NEUROLOGY & SPINE DISORDERS LLC
Entity Type:Organization
Organization Name:NEUROLOGY & SPINE DISORDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:FALCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-274-7118
Mailing Address - Street 1:1673 MASON AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5515
Mailing Address - Country:US
Mailing Address - Phone:386-274-7118
Mailing Address - Fax:386-274-6173
Practice Address - Street 1:5111 S RIDGEWOOD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-5169
Practice Address - Country:US
Practice Address - Phone:386-763-4484
Practice Address - Fax:386-763-1288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME460052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000EZOtherBLUE CROSS BLUE SHIELD
FLDQ2689OtherRAILROAD MEDICARE
FLDQ2689OtherRAILROAD MEDICARE