Provider Demographics
NPI:1013515451
Name:GULF COAST NEUROSPA LLC
Entity Type:Organization
Organization Name:GULF COAST NEUROSPA LLC
Other - Org Name:BRIDGEWATER TMS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VYVERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-277-1771
Mailing Address - Street 1:8845 LORRAINE ROAD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-277-1771
Mailing Address - Fax:866-740-0655
Practice Address - Street 1:8845 LORRAINE ROAD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-277-1771
Practice Address - Fax:866-740-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-16
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty