Healthcare Provider Details

I. General information

NPI: 1770084063
Provider Name (Legal Business Name): NEUROSHIELD NETWORK SE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 SUNSET BLVD
WEST COLUMBIA SC
29169-5914
US

IV. Provider business mailing address

1304 SUNSET BLVD
WEST COLUMBIA SC
29169-5914
US

V. Phone/Fax

Practice location:
  • Phone: 888-329-0807
  • Fax:
Mailing address:
  • Phone: 888-329-0807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CAREY POWELL
Title or Position: BILLING DIRECTOR SE
Credential:
Phone: 888-329-0807