Healthcare Provider Details

I. General information

NPI: 1952828949
Provider Name (Legal Business Name): COLONY DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11533 BUSY ST # 305
NORTH CHESTERFIELD VA
23236-4073
US

IV. Provider business mailing address

11533 BUSY ST # 305
NORTH CHESTERFIELD VA
23236-4073
US

V. Phone/Fax

Practice location:
  • Phone: 540-595-0795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY DELONG
Title or Position: NPI REPRESENTATIVE
Credential:
Phone: 210-598-2800