Healthcare Provider Details

I. General information

NPI: 1104254655
Provider Name (Legal Business Name): NEUROLOGIX DIAGNOSTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2013
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 CENTRE CIR STE 1018
ALTAMONTE SPRINGS FL
32714-7242
US

IV. Provider business mailing address

2415 S VOLUSIA AVE STE A2
ORANGE CITY FL
32763-7623
US

V. Phone/Fax

Practice location:
  • Phone: 321-320-9601
  • Fax:
Mailing address:
  • Phone: 386-775-6879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LEONARD A. ROLLMAN
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 321-320-9601