Healthcare Provider Details

I. General information

NPI: 1194093278
Provider Name (Legal Business Name): NEURODX ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5485 BETHELVIEW RD STE 360-333
CUMMING GA
30040-9735
US

IV. Provider business mailing address

5290 MATT HWY STE 502-125
CUMMING GA
30028-8629
US

V. Phone/Fax

Practice location:
  • Phone: 239-482-0300
  • Fax:
Mailing address:
  • Phone: 813-355-9105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License NumberCH8431
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS7123
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License NumberCH8431
License Number StateFL

VIII. Authorized Official

Name: DR. GEORGE S PETRYK
Title or Position: MANAGING MEMBER
Credential: D.C., D.A.C.N.B.
Phone: 239-482-0300