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General NPI Number Information
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NPI Number | 1942569843
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Entity Type | Organization
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Legal Business Name | INTRANERVE LLC
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Dates
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Enumeration Date | 05/11/2012
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Last Update Date | 05/11/2012
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Provider Practice Location Address
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Address Line | 2210 ABBEYWOOD DR STE A
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City | LISLE
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State | IL
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Zip | 60532-3384
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Country | US
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Telephone | 331-330-3336
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Fax |
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Provider Business Mailing Address
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Address Line | 2210 ABBEYWOOD DR STE A
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City | LISLE
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State | IL
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Zip | 60532-3384
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Country | US
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Telephone | 331-330-3336
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Fax |
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Authorized Official
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Title or Position | DIR. OF OPERATONS MIDWEST.
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Name | MICHAEL L. KOSTREVA
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Credential | BS CNIM
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Telephone | 331-330-3336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZE0600X
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Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
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License Number | 246ZE0600X
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License Number State | IL
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