Healthcare Provider Details

I. General information

NPI: 1386190734
Provider Name (Legal Business Name): BRAIN SPINE AND SLEEP INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 CARLTON AVE SUITE 1300
LAKE WALES FL
33853-4347
US

IV. Provider business mailing address

1120 CARLTON AVE SUITE 1300
LAKE WALES FL
33853-4347
US

V. Phone/Fax

Practice location:
  • Phone: 863-676-6386
  • Fax: 863-676-3124
Mailing address:
  • Phone: 863-676-6386
  • Fax: 863-676-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: HASAN M MOUSLI
Title or Position: OWNER/MD
Credential: MD
Phone: 863-676-6386