Provider Demographics
NPI:1689128266
Name:AMPLIFIED NEURODIAGNOSTICS, P. A.
Entity Type:Organization
Organization Name:AMPLIFIED NEURODIAGNOSTICS, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-580-4189
Mailing Address - Street 1:2260 N 29TH AVE
Mailing Address - Street 2:UNIT 302
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1710
Mailing Address - Country:US
Mailing Address - Phone:717-580-4189
Mailing Address - Fax:
Practice Address - Street 1:2260 N 29TH AVE
Practice Address - Street 2:UNIT 302
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1710
Practice Address - Country:US
Practice Address - Phone:717-580-4189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11618305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service