Provider Demographics
NPI:1407026354
Name:INFONEURO GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:INFONEURO GROUP, A MEDICAL CORPORATION
Other - Org Name:INFONEURO GROUP, A MEDICAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GALLIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-597-0600
Mailing Address - Street 1:PO BOX 12843
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-3843
Mailing Address - Country:US
Mailing Address - Phone:909-597-0600
Mailing Address - Fax:909-597-0655
Practice Address - Street 1:415 N CRESCENT DR STE 220
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-6810
Practice Address - Country:US
Practice Address - Phone:909-567-0600
Practice Address - Fax:909-597-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA729282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16085Medicare PIN