Healthcare Provider Details

I. General information

NPI: 1144564477
Provider Name (Legal Business Name): QUALITY NEURO SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 W BROADWAY SUITE B201
ANAHEIM CA
92804-2374
US

IV. Provider business mailing address

PO BOX 2864
ANAHEIM CA
92814-0864
US

V. Phone/Fax

Practice location:
  • Phone: 818-600-1572
  • Fax: 877-625-7254
Mailing address:
  • Phone: 818-600-1572
  • Fax: 877-625-7254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberME94218
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number2124
License Number StateTX

VIII. Authorized Official

Name: JULIO CANTERO
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 818-600-1572