Provider Demographics
NPI:1487102208
Name:NEUROVERSION
Entity type:Organization
Organization Name:NEUROVERSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-523-5372
Mailing Address - Street 1:2925 DEBARR RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2959
Mailing Address - Country:US
Mailing Address - Phone:818-523-5372
Mailing Address - Fax:
Practice Address - Street 1:2925 DEBARR RD
Practice Address - Street 2:SUITE 240
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2959
Practice Address - Country:US
Practice Address - Phone:907-339-4650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS6555208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1654351Medicaid