Healthcare Provider Details

I. General information

NPI: 1669818563
Provider Name (Legal Business Name): PHYSIOLOGIC DIAGNOSTIC SERVICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 SPECTRUM DR STE 1100E
ADDISON TX
75001-4688
US

IV. Provider business mailing address

1141 N LOOP 1604 E # 105-612
SAN ANTONIO TX
78232-1339
US

V. Phone/Fax

Practice location:
  • Phone: 469-283-1988
  • Fax: 210-566-1330
Mailing address:
  • Phone: 469-283-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: ROXANNA LAROQUE
Title or Position: DIRECTOR OF CLIENT EXPERIENCE
Credential:
Phone: 210-598-2801