Healthcare Provider Details

I. General information

NPI: 1952803298
Provider Name (Legal Business Name): HEARTLAND NEUROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 W HICKPOCHEE AVE UNIT C
LABELLE FL
33935-4330
US

IV. Provider business mailing address

777 W HICKPOCHEE AVE UNIT C
LABELLE FL
33935-4330
US

V. Phone/Fax

Practice location:
  • Phone: 863-230-6950
  • Fax: 208-275-0119
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberME117089
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME117089
License Number StateFL

VIII. Authorized Official

Name: MR. JAY CARRINGTON GOULD JR.
Title or Position: OFFICE MANAGER
Credential:
Phone: 239-542-0939