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General NPI Number Information
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NPI Number | 1194889709
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Entity Type | Organization
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Legal Business Name | BAY AREA NEURO CLINIC INC
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6275 E FOWLER AVE
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City | TEMPLE TERRACE
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State | FL
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Zip | 33617
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Country | US
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Telephone | 813-985-3773
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Fax | 813-984-7171
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Provider Business Mailing Address
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Address Line | 6275 E FOWLER AVE
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City | TEMPLE TERRACE
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State | FL
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Zip | 33617
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Country | US
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Telephone | 813-985-3773
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Fax | 813-984-7171
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOSE VICENTE BUSTAMANTE
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Credential | LICENSE MASSAGE THER
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Telephone | 813-985-3773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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