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General NPI Number Information
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NPI Number | 1912497827
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Entity Type | Organization
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Legal Business Name | MID FLORIDA NEURO DAYTONA, LLC
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Dates
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Enumeration Date | 05/16/2018
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Last Update Date | 05/16/2018
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Provider Practice Location Address
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Address Line | 1020 MASON AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32117-4612
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Country | US
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Telephone | 386-317-5149
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Fax |
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Provider Business Mailing Address
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Address Line | 807 BEVILLE RD
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City | SOUTH DAYTONA
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State | FL
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Zip | 32119-1824
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Country | US
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Telephone | 386-456-4878
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HARRY VASSILAKIS
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Credential |
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Telephone | 386-212-8612
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | ME91672
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License Number State | FL
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