MEDICARE: QUALITY NEURO SUPPLY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist	2124	TX
2	2084N0600X	Clinical Neurophysiology Physician	ME94218	FL

General Provider Information

NPI Number	:	1144564477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALITY NEURO SUPPLY LLC

Provider Business Mailing Address
First Line	:	PO BOX 2864
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92814-0864
Country	:	US
Telephone Number	:	818-600-1572
Fax Number	:	877-625-7254

Provider Business Practice Location Address
First Line	:	2201 W BROADWAY
Second Line	:	SUITE B201
City	:	ANAHEIM
State	:	CA
Zip	:	92804-2374
Country	:	US
Telephone Number	:	818-600-1572
Fax Number	:	877-625-7254

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	JULIO CANTERO
Credential	:	M.D.
Telephone Number	:	818-600-1572

Provider Enumeration Date	:	11/27/2012
Last Update Date	:	11/27/2012

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