=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376002865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROTECH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2019
-----------------------------------------------------
Last Update Date | 03/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 269 SHEFFIELD ST
-----------------------------------------------------
City | MOUNTAINSIDE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07092-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-875-6627
-----------------------------------------------------
Fax | 262-754-0897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 626 W MORELAND BLVD
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-875-6572
-----------------------------------------------------
Fax | 262-754-0897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CONTRACTING & RESEARCH
-----------------------------------------------------
Name | KRISTINE LISA WILDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-875-6572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZE0500X
-----------------------------------------------------
Taxonomy Name | EEG Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------