Provider Demographics
NPI:1891106712
Name:MARINA CENTER NEURODIAGNOSTICS INC
Entity Type:Organization
Organization Name:MARINA CENTER NEURODIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARDS
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-201-3874
Mailing Address - Street 1:3011 GRAYSON AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4651
Mailing Address - Country:US
Mailing Address - Phone:562-201-3874
Mailing Address - Fax:866-441-8248
Practice Address - Street 1:3011 GRAYSON AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4651
Practice Address - Country:US
Practice Address - Phone:562-201-3874
Practice Address - Fax:866-441-8248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3298806208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty