Healthcare Provider Details

I. General information

NPI: 1952391989
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA NEURODIAGNOSTIC CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5212 KATELLA AVE SUITE 106
LOS ALAMITOS CA
90720-2828
US

IV. Provider business mailing address

133 THE PROMENADE N STE 108
LONG BEACH CA
90802-4728
US

V. Phone/Fax

Practice location:
  • Phone: 562-495-3937
  • Fax: 562-206-0371
Mailing address:
  • Phone: 562-495-3937
  • Fax: 562-206-0371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: BRADY BRAYTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 562-495-3937