Provider Demographics
NPI:1790075208
Name:NEURO FOCUS CENTER LLC
Entity Type:Organization
Organization Name:NEURO FOCUS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALDECK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-315-7033
Mailing Address - Street 1:1400 NORTH GILBERT ROAD
Mailing Address - Street 2:SUITE H
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2726
Mailing Address - Country:US
Mailing Address - Phone:480-632-2301
Mailing Address - Fax:480-813-4534
Practice Address - Street 1:1400 NORTH GILBERT ROAD
Practice Address - Street 2:SUITE H
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2726
Practice Address - Country:US
Practice Address - Phone:480-632-2301
Practice Address - Fax:480-813-4534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33521261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ611096Medicaid
AZZ150423Medicare UPIN