Provider Demographics
NPI:1205017944
Name:CLINICAL NEURO DX, LLC
Entity type:Organization
Organization Name:CLINICAL NEURO DX, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER, CLINICAL NEUROPHYSIOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ATEER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:CNLM, MS
Authorized Official - Phone:404-419-1319
Mailing Address - Street 1:PO BOX 2259
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-0057
Mailing Address - Country:US
Mailing Address - Phone:404-419-1319
Mailing Address - Fax:866-209-0284
Practice Address - Street 1:260 PEACHTREE ST NW STE 2200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1292
Practice Address - Country:US
Practice Address - Phone:404-419-1319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY639261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA639OtherCNLM