Provider Demographics
NPI:1952535122
Name:MCNEILL, K MARIO (CRT, MMBT)
Entity Type:Individual
Prefix:
First Name:K MARIO
Middle Name:
Last Name:MCNEILL
Suffix:
Gender:M
Credentials:CRT, MMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 HILLS LN
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-8412
Mailing Address - Country:US
Mailing Address - Phone:919-418-6686
Mailing Address - Fax:
Practice Address - Street 1:2135 VALLEYGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3750
Practice Address - Country:US
Practice Address - Phone:910-323-2247
Practice Address - Fax:910-486-8064
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC246ZE0600X, 2472E0500X, 246ZE0500X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist