Healthcare Provider Details

I. General information

NPI: 1225530637
Provider Name (Legal Business Name): IOM NEURO PRO READER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 SANTA ANITA AVE SUITE 101
RANCHO CUCAMONGA CA
91730
US

IV. Provider business mailing address

9300 SANTA ANITA AVE SUITE 101
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 909-373-4633
  • Fax: 909-343-5228
Mailing address:
  • Phone: 909-373-4633
  • Fax: 909-343-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG57315
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberG57315
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberG57315
License Number StateCA

VIII. Authorized Official

Name: MR. ANDREW SCHREIBER
Title or Position: CEO
Credential: M.D.
Phone: 909-373-4633