=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225853310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROGLEE CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2024
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 PEACHTREE PKWY STE 4245
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-411-7686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 ARCH ST FL 8
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02110-7500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-411-7686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | RAVI JAIMINI PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-878-0070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------