Provider Demographics
NPI:1033650510
Name:GRAND CANYON NEUROLOGY, PLLC
Entity Type:Organization
Organization Name:GRAND CANYON NEUROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEGAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDERETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-598-2801
Mailing Address - Street 1:MSC 334 PO BOX 29201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9201
Mailing Address - Country:US
Mailing Address - Phone:602-338-9745
Mailing Address - Fax:
Practice Address - Street 1:10025 E DYNAMITE BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262
Practice Address - Country:US
Practice Address - Phone:602-338-9745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty