Healthcare Provider Details

I. General information

NPI: 1518127067
Provider Name (Legal Business Name): NEUROLOGY SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 E BOULDER ST
COLORADO SPRINGS CO
80909-5663
US

IV. Provider business mailing address

1519 E BOULDER ST
COLORADO SPRINGS CO
80909-5663
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5155
  • Fax:
Mailing address:
  • Phone: 719-632-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number23688
License Number StateCO

VIII. Authorized Official

Name: MARIO M OLIVEIRA
Title or Position: OWNER
Credential: MD
Phone: 719-632-5155