MEDICARE: SCOTTSDALE PROFESSIONAL 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	:	1790217792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTTSDALE PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 96
Second Line	:
City	:	MILAM
State	:	TX
Zip	:	75959-0096
Country	:	US
Telephone Number	:	225-588-4845
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	:	MANAGER
Name	:	KATHY REED
Credential	:
Telephone Number	:	720-503-5711

Provider Enumeration Date	:	03/29/2017
Last Update Date	:	05/01/2017

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Directions to “SCOTTSDALE PROFESSIONAL LLC ” Practice Location

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