=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922698091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST WAVE NEURODIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2021
-----------------------------------------------------
Last Update Date | 05/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 937 E MAIN ST STE 107
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-357-5272
-----------------------------------------------------
Fax | 805-308-7107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 937 E MAIN ST STE 107
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-357-5272
-----------------------------------------------------
Fax | 805-308-7107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, REGISTERED EEG TECHNOLOGIST
-----------------------------------------------------
Name | JESSICA JEWEL MORROW
-----------------------------------------------------
Credential | R.EEGT
-----------------------------------------------------
Telephone | 805-540-1160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156F00000X
-----------------------------------------------------
Taxonomy Name | Technician/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------