=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467926006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDEAL NEUROLOGY CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2019
-----------------------------------------------------
Last Update Date | 12/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 W PALMETTO PARK RD STE 406
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-3425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-961-8575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 880761
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33488-0761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-961-8575
-----------------------------------------------------
Fax | 561-898-1710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER/CEO/MEDICAL DIRECTO
-----------------------------------------------------
Name | RENATA CHALFIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-961-8575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------