Provider Demographics
NPI:1972979888
Name:INNERVATE NEUROLOGY CLINIC, INC.
Entity Type:Organization
Organization Name:INNERVATE NEUROLOGY CLINIC, INC.
Other - Org Name:INNERVATE MUSCLE AND NERVE SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AURELIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUZAURIETA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:904-631-2669
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-1450
Mailing Address - Country:US
Mailing Address - Phone:904-298-2525
Mailing Address - Fax:904-677-7873
Practice Address - Street 1:14810 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 207B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2451
Practice Address - Country:US
Practice Address - Phone:904-298-2525
Practice Address - Fax:904-677-7873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1228802081N0008X, 2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty