Healthcare Provider Details

I. General information

NPI: 1720162514
Provider Name (Legal Business Name): ACTIVE DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MARYLAND FARMS STE 200
BRENTWOOD TN
37027-5005
US

IV. Provider business mailing address

3 MARYLAND FARMS STE 200
BRENTWOOD TN
37027-5005
US

V. Phone/Fax

Practice location:
  • Phone: 800-348-4565
  • Fax: 615-345-5405
Mailing address:
  • Phone: 800-348-4565
  • Fax: 615-345-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY GRAY
Title or Position: EXECUTIVE VICE PRESIDENT, CFO AND C
Credential:
Phone: 800-348-4565