Healthcare Provider Details

I. General information

NPI: 1760004501
Provider Name (Legal Business Name): TREASURE COAST NEUROLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 FRIST BLVD STE 2B
FORT PIERCE FL
34950-4800
US

IV. Provider business mailing address

2401 FRIST BLVD STE 2B
FORT PIERCE FL
34950-4800
US

V. Phone/Fax

Practice location:
  • Phone: 772-528-1310
  • Fax:
Mailing address:
  • Phone: 772-528-1310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAUL EDUARDO MONTEJO
Title or Position: OWNER/NEUROLOGIST
Credential: M.D.
Phone: 772-528-1310