Provider Demographics
NPI:1720637317
Name:NEUROPHYSIOLOGY DIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:NEUROPHYSIOLOGY DIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-871-2853
Mailing Address - Street 1:4102 N MACDILL AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6717
Mailing Address - Country:US
Mailing Address - Phone:813-871-2853
Mailing Address - Fax:813-877-1609
Practice Address - Street 1:4102 N MACDILL AVE UNIT B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6717
Practice Address - Country:US
Practice Address - Phone:813-871-2853
Practice Address - Fax:813-877-1609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
293D00000XOtherTAXONOMY