Provider Demographics
NPI:1639500192
Name:PEDIATRIC NEURODEVELOPMENTAL CENTER LLC
Entity Type:Organization
Organization Name:PEDIATRIC NEURODEVELOPMENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP/ OWNER/ MD
Authorized Official - Prefix:DR
Authorized Official - First Name:AVI
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOMNITZ-GEBET
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:636-778-9212
Mailing Address - Street 1:17300 N OUTER 40 RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1364
Mailing Address - Country:US
Mailing Address - Phone:636-778-9212
Mailing Address - Fax:
Practice Address - Street 1:17300 N OUTER 40 RD
Practice Address - Street 2:SUITE 205
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1364
Practice Address - Country:US
Practice Address - Phone:636-778-9212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty