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General NPI Number Information
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NPI Number | 1568769974
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Entity Type | Organization
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Legal Business Name | SOUTHERN NEURODIAGNOSTICS LLC
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Dates
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Enumeration Date | 02/21/2011
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Last Update Date | 07/27/2022
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Provider Practice Location Address
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Address Line | 5357 SHILOH RD
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City | HAHIRA
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State | GA
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Zip | 31632-2321
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Country | US
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Telephone | 229-740-7639
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Fax | 884-638-8738
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Provider Business Mailing Address
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Address Line | 5357 SHILOH RD
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City | HAHIRA
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State | GA
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Zip | 31632-2321
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Country | US
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Telephone | 292-740-7639
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Fax | 888-463-8873
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Authorized Official
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Title or Position | NP/OWNER
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Name | DARIN MELVIN
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Credential | NP
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Telephone | 229-740-7663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 054374
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License Number State | GA
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