=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407134141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCE NEUROLOGY CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2011
-----------------------------------------------------
Last Update Date | 07/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 RAMBLING RD
-----------------------------------------------------
City | PALESTINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75801-4666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-395-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21218 SAINT ANDREWS BLVD # 529
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-395-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RUSSELL PACKARD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 888-395-4007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | L5082
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------