Provider Demographics
NPI: | 1760704522 |
---|---|
Name: | NEUROWAVE DIAGNOSTICS, LLC |
Entity Type: | Organization |
Organization Name: | NEUROWAVE DIAGNOSTICS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | FANNIE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CLARK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 770-557-0885 |
Mailing Address - Street 1: | PO BOX 930905 |
Mailing Address - Street 2: | |
Mailing Address - City: | NORCROSS |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30003-0905 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 770-557-0885 |
Mailing Address - Fax: | 770-557-0315 |
Practice Address - Street 1: | 2227 IDLEWOOD RD |
Practice Address - Street 2: | SUITE 400 |
Practice Address - City: | TUCKER |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30084-4827 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-557-0885 |
Practice Address - Fax: | 770-557-0315 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-02-22 |
Last Update Date: | 2010-02-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 246ZE0600X | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic | Group - Single Specialty |