1497191241 NPI number — FUNCTIONAL NEUROLOGY ASSOCIATES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497191241 NPI number — FUNCTIONAL NEUROLOGY ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL NEUROLOGY ASSOCIATES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497191241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 GREAT ROAD
Provider Second Line Business Mailing Address:
SUITE #103
Provider Business Mailing Address City Name:
ACTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-429-8952
Provider Business Mailing Address Fax Number:
978-429-8953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 GREAT ROAD
Provider Second Line Business Practice Location Address:
SUITE #103
Provider Business Practice Location Address City Name:
ACTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-429-8952
Provider Business Practice Location Address Fax Number:
978-429-8953
Provider Enumeration Date:
05/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
978-429-8952

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NN0400X , with the licence number: CH2739CH3404 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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