Provider Demographics
NPI:1710282249
Name:NEUROSYNC
Entity Type:Organization
Organization Name:NEUROSYNC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:L.
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-699-4655
Mailing Address - Street 1:555 E 4500 S
Mailing Address - Street 2:STE C150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4533
Mailing Address - Country:US
Mailing Address - Phone:801-288-0747
Mailing Address - Fax:801-288-0761
Practice Address - Street 1:5801 FASHION BLVD
Practice Address - Street 2:STE 120
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-699-4655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTLN-2010-0114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000073206Medicare PIN