1710282249 NPI number — NEUROSYNC

Table of content: (NPI 1710282249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710282249 NPI number — NEUROSYNC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROSYNC
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:
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:
1710282249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 E 4500 S
Provider Second Line Business Mailing Address:
STE C150
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-4533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-288-0747
Provider Business Mailing Address Fax Number:
801-288-0761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5801 FASHION BLVD
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-6159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-699-4655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
L.
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-699-4655

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  LN-2010-0114 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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