=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215551304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROFLOW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2020
-----------------------------------------------------
Last Update Date | 06/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S INDEPENDENCE MALL E STE 701
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19106-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-701-9745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 S INDEPENDENCE MALL E STE 701
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19106-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-701-9745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEAD OF CLINICAL OPERATIONS
-----------------------------------------------------
Name | MR. MATTHEW ADAM MICLETTE
-----------------------------------------------------
Credential | MPH, MS, RN
-----------------------------------------------------
Telephone | 860-859-7322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------