Provider Demographics
NPI:1558987727
Name:PRO TECH IOM LLC
Entity Type:Organization
Organization Name:PRO TECH IOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:PIERCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAYCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-482-2282
Mailing Address - Street 1:2801 CENTERVILLE RD FIRST FLOOR
Mailing Address - Street 2:PMB #710
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3329 E BELL RD STE A2-A5
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2756
Practice Address - Country:US
Practice Address - Phone:602-482-2282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty