Provider Demographics
NPI:1396278321
Name:AVANTIS NEUROSCIENCE INC
Entity type:Organization
Organization Name:AVANTIS NEUROSCIENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-682-0182
Mailing Address - Street 1:1807 WILSHIRE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12401 WILSHIRE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1015
Practice Address - Country:US
Practice Address - Phone:323-682-0182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty