Healthcare Provider Details

I. General information

NPI: 1023560844
Provider Name (Legal Business Name): CENTER FOR NEUROFITNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5137
US

IV. Provider business mailing address

248 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5137
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-5680
  • Fax: 904-797-5681
Mailing address:
  • Phone: 904-797-5680
  • Fax: 904-797-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS H SWISSHELM
Title or Position: OWNER
Credential: MED, EDS, BCN
Phone: 904-797-5680