=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780696583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NECKSCAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 02/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1890 STATE ROAD 436 SUITE 201
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-2228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-679-7102
-----------------------------------------------------
Fax | 407-679-2922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 621590
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32762-1590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-679-7102
-----------------------------------------------------
Fax | 407-679-2922
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DAWN BAILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-679-7102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------