Healthcare Provider Details

I. General information

NPI: 1356643449
Provider Name (Legal Business Name): ELITE NEURODIAGNOSTICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5727 W AVENUE K2
LANCASTER CA
93536-5647
US

IV. Provider business mailing address

5727 W AVENUE K2
LANCASTER CA
93536-5647
US

V. Phone/Fax

Practice location:
  • Phone: 661-305-1029
  • Fax: 661-722-8333
Mailing address:
  • Phone: 661-305-1029
  • Fax: 661-722-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA LYNN ANDERSON
Title or Position: CEO
Credential:
Phone: 661-305-1029