Healthcare Provider Details

I. General information

NPI: 1407265259
Provider Name (Legal Business Name): AZLE NEUROMONITORING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 BOLING RANCH ROAD N
AZLE TX
76020
US

IV. Provider business mailing address

1244 BOLING RANCH ROAD N
AZLE TX
76020
US

V. Phone/Fax

Practice location:
  • Phone: 817-908-8124
  • Fax: 817-885-7339
Mailing address:
  • Phone: 817-908-8124
  • Fax: 817-885-7339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberN8651
License Number StateTX

VIII. Authorized Official

Name: DR. AUGUSTO CEZAR LASTIMOSA
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 817-908-8124