Provider Demographics
NPI:1407932312
Name:NEURODYNAMICS INC
Entity Type:Organization
Organization Name:NEURODYNAMICS INC
Other - Org Name:NEURODYNAMICS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWER
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:858-279-6772
Mailing Address - Street 1:2815 CAMINO DEL RIO S
Mailing Address - Street 2:STE 220
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3815
Mailing Address - Country:US
Mailing Address - Phone:858-279-6772
Mailing Address - Fax:858-279-7505
Practice Address - Street 1:2815 CAMINO DEL RIO S
Practice Address - Street 2:STE 220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3815
Practice Address - Country:US
Practice Address - Phone:858-279-6772
Practice Address - Fax:858-279-7505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEURODYNAMICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-31
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGAU000820Medicaid