=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235425943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NMS DIAGNOSTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2011
-----------------------------------------------------
Last Update Date | 08/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 GWYNEDD LEA DR
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-480-1606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 GWYNEDD LEA DR
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | ARMEN PETROSSIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-480-1606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN0400X
-----------------------------------------------------
Taxonomy Name | Neurology Chiropractor
-----------------------------------------------------
License Number | DC010470
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------