Provider Demographics
NPI:1629468541
Name:DEFINITIVE NEURODIAGNOSTICS, LLC PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:DEFINITIVE NEURODIAGNOSTICS, LLC PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ATWATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-454-1100
Mailing Address - Street 1:1604 VISA DR # 1
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1604 VISA DR # 1
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2195
Practice Address - Country:US
Practice Address - Phone:309-454-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEFINITIVE NEURODIAGNOSTICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100906246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty