MEDICARE: OLYMPIANEURO 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	:	1538563283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPIANEURO LLC

Provider Business Mailing Address
First Line	:	PO BOX 1191
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578-1191
Country	:	US
Telephone Number	:	713-446-1491
Fax Number	:	713-583-6635

Provider Business Practice Location Address
First Line	:	2938 WINCHASE BOULEVARD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-1864
Country	:	US
Telephone Number	:	713-446-1491
Fax Number	:	713-583-6635

Authorized Official
Title or Position	:	MEMBER
Name	:	KRESHON SMITH
Credential	:
Telephone Number	:	713-446-1491

Provider Enumeration Date	:	10/09/2014
Last Update Date	:	10/09/2014

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