Basic Information
| Provider Information | |||||||||
| NPI: | 1245429463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROWARD INSTITUTE OF NEURO SCIENCE L L C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7501 WILES RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330672063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543411022 | ||||||||
| FaxNumber: | 9543411082 | ||||||||
| Practice Location | |||||||||
| Address1: | 7501 WILES RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330672063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543411022 | ||||||||
| FaxNumber: | 9543411082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ESPAILLAT | ||||||||
| AuthorizedOfficialFirstName: | RICARDO | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR/CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 9543411022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | BE8849854 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.