Healthcare Provider Details

I. General information

NPI: 1427380278
Provider Name (Legal Business Name): WESTERN COLORADO TECHNICAL NEUROMONITORING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 ALLEN ADALE RD
FAIRBANKS AK
99709-2580
US

IV. Provider business mailing address

PO BOX 413136
SALT LAKE CITY UT
84141-3136
US

V. Phone/Fax

Practice location:
  • Phone: 225-588-4845
  • Fax: 225-612-6561
Mailing address:
  • Phone: 225-588-4845
  • Fax: 225-612-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: JOHN LOPEZ
Title or Position: OWNER
Credential: MD
Phone: 225-588-4845