=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679064638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROTECH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2018
-----------------------------------------------------
Last Update Date | 03/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4609 MILL BRANCH LN
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37938-3260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-851-8354
-----------------------------------------------------
Fax | 262-754-0897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 626 W MORELAND BLVD
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-754-0898
-----------------------------------------------------
Fax | 262-754-0897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CONTRACTING AND RESEARC
-----------------------------------------------------
Name | KRISTINE LISA WILDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-875-6572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2472E0500X
-----------------------------------------------------
Taxonomy Name | EEG Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------