Healthcare Provider Details

I. General information

NPI: 1669969564
Provider Name (Legal Business Name): SOUTHWEST NEURODIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42104 N VENTURE DR STE A114
ANTHEM AZ
85086-3825
US

IV. Provider business mailing address

42104 N VENTURE DR STE A114
ANTHEM AZ
85086-3825
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 406-599-4354
  • Fax: 602-798-8296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: CODY D DAVIES
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 406-599-4354