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General NPI Number Information
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NPI Number | 1013281740
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Entity Type | Organization
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Legal Business Name | WESTERN REGIONAL NEUROLOGY, LLC
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Dates
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Enumeration Date | 02/27/2012
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Last Update Date | 02/27/2012
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Provider Practice Location Address
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Address Line | 2005 INJO DR SUITE 103
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5874
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Country | US
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Telephone | 865-531-0176
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Fax | 865-531-0722
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Provider Business Mailing Address
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Address Line | 2005 INJO DR SUITE 103
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5874
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Country | US
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Telephone | 865-531-0176
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Fax | 865-531-0722
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Authorized Official
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Title or Position | OWNER
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Name | CAMILLE YVONNE KEENE
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Credential | MD
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Telephone | 865-531-0176
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 45845
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License Number State | AZ
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