=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093128084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROSPECT OF FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2014
-----------------------------------------------------
Last Update Date | 06/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 S PARK AVE
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32796-3377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-266-1881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 S PARK AVE
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32796-3377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-266-1881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRIAN BALDWIN
-----------------------------------------------------
Credential | CNMT,RT
-----------------------------------------------------
Telephone | 321-266-1881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number | CRT49346
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------