Provider Demographics
NPI:1194813279
Name:NEURO INSTITUTE, INC
Entity type:Organization
Organization Name:NEURO INSTITUTE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:OVETA
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-735-0124
Mailing Address - Street 1:1221 W WARNER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1906
Mailing Address - Country:US
Mailing Address - Phone:480-735-0124
Mailing Address - Fax:480-735-0126
Practice Address - Street 1:1221 W WARNER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1906
Practice Address - Country:US
Practice Address - Phone:480-735-0124
Practice Address - Fax:480-735-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 3407225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ72663Medicare ID - Type UnspecifiedOUTPATIENT CLINIC