Provider Demographics
NPI:1770124133
Name:NEUROGLYMPSE, LLC
Entity type:Organization
Organization Name:NEUROGLYMPSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, MANAGER, & MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:COREY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CONN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-345-7246
Mailing Address - Street 1:49 HUMMINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4505
Mailing Address - Country:US
Mailing Address - Phone:985-345-7246
Mailing Address - Fax:
Practice Address - Street 1:49 HUMMINGBIRD RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4505
Practice Address - Country:US
Practice Address - Phone:985-345-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty