Healthcare Provider Details

I. General information

NPI: 1659941185
Provider Name (Legal Business Name): NEUROTECH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 TIMBERLACHEN CIR STE 1001
LAKE MARY FL
32746-3303
US

IV. Provider business mailing address

626 W MORELAND BLVD
WAUKESHA WI
53188-2433
US

V. Phone/Fax

Practice location:
  • Phone: 262-875-6640
  • Fax: 262-754-0897
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: KRISTINE LISA WILDNER
Title or Position: DIRECTOR OF CONTRACTING AND RESEARC
Credential:
Phone: 262-875-6572