Healthcare Provider Details

I. General information

NPI: 1528818838
Provider Name (Legal Business Name): NEUROCITY TBI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 W STATE ROAD 84 STE 208
DAVIE FL
33324-4235
US

IV. Provider business mailing address

817 S UNIVERSITY DR STE 119
PLANTATION FL
33324-3318
US

V. Phone/Fax

Practice location:
  • Phone: 954-279-2170
  • Fax:
Mailing address:
  • Phone: 954-424-9724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MARISA MERLO
Title or Position: ACCOUNTS RECEIVABLE
Credential:
Phone: 954-279-2170