MEDICARE: PERFECT NERVE IOM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1386187722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFECT NERVE IOM LLC

Provider Business Mailing Address
First Line	:	18521 E QUEEN CREEK RD
Second Line	:	STE 105-161
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-5866
Country	:	US
Telephone Number	:	720-503-5711
Fax Number	:	602-926-8841

Provider Business Practice Location Address
First Line	:	18521 E QUEEN CREEK RD
Second Line	:	STE 105-161
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-5866
Country	:	US
Telephone Number	:	720-503-5711
Fax Number	:	602-926-8841

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KATHY REED
Credential	:
Telephone Number	:	720-503-5711

Provider Enumeration Date	:	12/01/2016
Last Update Date	:	12/01/2016

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