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General NPI Number Information
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NPI Number | 1396278321
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Entity Type | Organization
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Legal Business Name | AVANTIS NEUROSCIENCE INC
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Dates
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Enumeration Date | 04/06/2017
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Last Update Date | 01/23/2020
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Provider Practice Location Address
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Address Line | 12401 WILSHIRE BLVD STE 104
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City | LOS ANGELES
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State | CA
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Zip | 90025-1015
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Country | US
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Telephone | 323-682-0182
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Fax |
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Provider Business Mailing Address
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Address Line | 1807 WILSHIRE BLVD STE A
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City | SANTA MONICA
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State | CA
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Zip | 90403-5678
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. JEFFREY M CHUNG
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Credential | M.D.
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Telephone | 323-682-0182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number |
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License Number State |
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