MEDICARE: PONTE VEDRA NEUROPSYCHOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist
2	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1114624277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONTE VEDRA NEUROPSYCHOLOGY LLC

Provider Business Mailing Address
First Line	:	176 PARKBLUFF CIR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-0958
Country	:	US
Telephone Number	:	904-303-8362
Fax Number	:

Provider Business Practice Location Address
First Line	:	4210 VALLEY RIDGE BLVD STE 113
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5171
Country	:	US
Telephone Number	:	904-303-8362
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. KARI ENG
Credential	:
Telephone Number	:	904-303-8362

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	02/09/2023

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