=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780247734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VOLUSIA BRAIN AND SPINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 04/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 OSCEOLA AVE
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32176-6638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-405-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 OSCEOLA AVE
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32176-6638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-405-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTOPHER S KENT
-----------------------------------------------------
Credential | MBR
-----------------------------------------------------
Telephone | 386-405-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------