=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104264035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABEA NEURODIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2013
-----------------------------------------------------
Last Update Date | 06/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 ORANGE AVE SUITE 202
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90630-2959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-394-6100
-----------------------------------------------------
Fax | 909-394-6117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10460 ROSE ANN CIR
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90630-4359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-394-6100
-----------------------------------------------------
Fax | 909-394-6117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | DR. DORMEL M ABEA
-----------------------------------------------------
Credential | CNIM
-----------------------------------------------------
Telephone | 626-488-6495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number | 1461
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------