Provider Demographics
NPI:1912070368
Name:NEURODIAGNOSTIC LABORATORIES, LLC
Entity type:Organization
Organization Name:NEURODIAGNOSTIC LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-424-4450
Mailing Address - Street 1:2423 W DUNLAP AVE
Mailing Address - Street 2:#130
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5818
Mailing Address - Country:US
Mailing Address - Phone:602-424-4450
Mailing Address - Fax:602-424-4451
Practice Address - Street 1:2423 W DUNLAP AVE
Practice Address - Street 2:#130
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5818
Practice Address - Country:US
Practice Address - Phone:602-424-4450
Practice Address - Fax:602-424-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ114239Medicare PIN