Provider Demographics
NPI:1467685461
Name:CHILD AND ADOLESCENT NEUROLOGY PROF LLC
Entity Type:Organization
Organization Name:CHILD AND ADOLESCENT NEUROLOGY PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-334-8000
Mailing Address - Street 1:PO BOX 89432
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57109-9432
Mailing Address - Country:US
Mailing Address - Phone:605-334-8000
Mailing Address - Fax:605-334-8001
Practice Address - Street 1:117 W 39TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5732
Practice Address - Country:US
Practice Address - Phone:605-334-8000
Practice Address - Fax:605-334-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025804700Medicaid
ND15135Medicaid
SDS103671Medicare PIN