=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093041444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO NEURODIAGNOSTICO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2009
-----------------------------------------------------
Last Update Date | 10/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | A2 CALLE LODI VILLA LUARCA
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-3804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-751-5955
-----------------------------------------------------
Fax | 787-767-0516
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | A2 CALLE LODI VILLA LUARCA
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-3804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-751-5955
-----------------------------------------------------
Fax | 787-767-0516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NORMA E AGOSTO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-751-5955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number | 4731
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------