Basic Information
| Provider Information | |||||||||
| NPI: | 1669969564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST NEURODIAGNOSTICS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 42104 N VENTURE DR STE A114 | ||||||||
| Address2: | |||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850863825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065994354 | ||||||||
| FaxNumber: | 6027988296 | ||||||||
| Practice Location | |||||||||
| Address1: | 42104 N VENTURE DR STE A114 | ||||||||
| Address2: | |||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850863825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIES | ||||||||
| AuthorizedOfficialFirstName: | CODY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4065994354 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0500X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | EEG | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.