Provider Demographics
NPI:1568769974
Name:SOUTHERN NEURODIAGNOSTICS LLC
Entity Type:Organization
Organization Name:SOUTHERN NEURODIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:229-740-7663
Mailing Address - Street 1:5357 SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-2321
Mailing Address - Country:US
Mailing Address - Phone:292-740-7639
Mailing Address - Fax:888-463-8873
Practice Address - Street 1:5357 SHILOH RD
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-2321
Practice Address - Country:US
Practice Address - Phone:229-740-7639
Practice Address - Fax:884-638-8738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty