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General NPI Number Information
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NPI Number | 1609489988
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Entity Type | Organization
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Legal Business Name | VIVID NEUROLOGY PC
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Dates
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Enumeration Date | 08/26/2020
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Last Update Date | 08/26/2020
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Provider Practice Location Address
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Address Line | 26400 W 12 MILE RD STE 20
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1774
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Country | US
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Telephone | 248-864-8752
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Fax | 248-920-0744
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Provider Business Mailing Address
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Address Line | 26400 W 12 MILE RD STE 20
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1774
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Country | US
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Telephone | 248-864-8752
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Fax | 248-920-0744
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Authorized Official
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Title or Position | MANAGER
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Name | REMONDA ELYAS
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Credential |
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Telephone | 248-864-8752
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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