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General NPI Number Information
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NPI Number | 1104954049
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Entity Type | Organization
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Legal Business Name | ADVANCED NEUROSCIENCE CLINIC, PA
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 601 E 2ND ST STE E
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City | ODESSA
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State | TX
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Zip | 79761-5435
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Country | US
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Telephone | 432-570-9991
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Fax | 432-687-6299
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Provider Business Mailing Address
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Address Line | PO BOX 4100
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City | MIDLAND
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State | TX
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Zip | 79704-4100
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Country | US
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Telephone | 432-570-9991
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Fax | 432-687-6299
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Authorized Official
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Title or Position | BUSINESS OFFICE MGR.
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Name | CHAD HAGGERTON
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Credential |
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Telephone | 432-687-6203
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | M3833
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number | L2914
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number | M3833
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 2084S0012X
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Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
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License Number | L2914
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA04008
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License Number State | TX
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Taxonomy #6
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | L2914
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License Number State | TX
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