Provider Demographics
NPI:1912497827
Name:MID FLORIDA NEURO DAYTONA, LLC
Entity Type:Organization
Organization Name:MID FLORIDA NEURO DAYTONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSILAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-212-8612
Mailing Address - Street 1:807 BEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1824
Mailing Address - Country:US
Mailing Address - Phone:386-456-4878
Mailing Address - Fax:
Practice Address - Street 1:1020 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4612
Practice Address - Country:US
Practice Address - Phone:386-317-5149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91672261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty