Basic Information
| Provider Information | |||||||||
| NPI: | 1952535122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNEILL | ||||||||
| FirstName: | K MARIO | ||||||||
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| Credential: | CRT, MMBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 HILLS LN | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283398412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194186686 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2135 VALLEYGATE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103232247 | ||||||||
| FaxNumber: | 9104868064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2009 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | NC | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic | 2472E0500X | NC | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | EEG | 246ZE0500X | NC | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | EEG | 225700000X | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.