Provider Demographics
NPI:1811177264
Name:SOUTH FLORIDA NEUROLOGICAL
Entity type:Organization
Organization Name:SOUTH FLORIDA NEUROLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CICCONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-941-1399
Mailing Address - Street 1:601 E SAMPLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-4443
Mailing Address - Country:US
Mailing Address - Phone:954-941-1399
Mailing Address - Fax:954-941-3103
Practice Address - Street 1:601 E SAMPLE RD STE 104
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-4443
Practice Address - Country:US
Practice Address - Phone:954-941-1399
Practice Address - Fax:954-941-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty