Provider Demographics
NPI:1760704522
Name:NEUROWAVE DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:NEUROWAVE DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-557-0885
Mailing Address - Street 1:PO BOX 930905
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30003-0905
Mailing Address - Country:US
Mailing Address - Phone:770-557-0885
Mailing Address - Fax:770-557-0315
Practice Address - Street 1:2227 IDLEWOOD RD
Practice Address - Street 2:SUITE 400
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4827
Practice Address - Country:US
Practice Address - Phone:770-557-0885
Practice Address - Fax:770-557-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty