Provider Demographics
NPI:1790199859
Name:NEUROTECH, LLC
Entity Type:Organization
Organization Name:NEUROTECH, LLC
Other - Org Name:NEUROTECH INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING & RESEARCH
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:WILDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-875-6572
Mailing Address - Street 1:626 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2433
Mailing Address - Country:US
Mailing Address - Phone:262-754-0898
Mailing Address - Fax:
Practice Address - Street 1:941 E 86TH ST STE 107
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1842
Practice Address - Country:US
Practice Address - Phone:262-875-6611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEUROTECH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-17
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological Laboratory
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEGGroup - Single Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Single Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201132380AMedicaid
ININ1268Medicare UPIN