Basic Information
| Provider Information | |||||||||
| NPI: | 1912065558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVE DIAGNOSTICS OF NV LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 216 F ST | ||||||||
| Address2: | #76 | ||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306688988 | ||||||||
| FaxNumber: | 5306681229 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 F ST | ||||||||
| Address2: | #76 | ||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956164515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306688988 | ||||||||
| FaxNumber: | 5306681229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONKS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5306688988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
ID Information
| ID | Type | State | Issuer | Description | A02500003857 | 01 | NV | HPN | OTHER |