Provider Demographics
NPI:1700102753
Name:NEUROLOGICAL CARE CLINIC PC
Entity Type:Organization
Organization Name:NEUROLOGICAL CARE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRUFO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-951-5090
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24068-0126
Mailing Address - Country:US
Mailing Address - Phone:540-951-5090
Mailing Address - Fax:540-552-2500
Practice Address - Street 1:825 DAVIS ST
Practice Address - Street 2:SUITE D
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7013
Practice Address - Country:US
Practice Address - Phone:540-951-5090
Practice Address - Fax:540-552-3100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238524174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010275091Medicaid
VA155543Medicare UPIN