Healthcare Provider Details

I. General information

NPI: 1871808089
Provider Name (Legal Business Name): MT NEURODIAGNOSTIXS MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 RUNNING BEAR TRL
CROSBY TX
77532-3618
US

IV. Provider business mailing address

PO BOX 1651
CROSBY TX
77532-1651
US

V. Phone/Fax

Practice location:
  • Phone: 281-462-7684
  • Fax: 888-832-5078
Mailing address:
  • Phone: 281-462-7684
  • Fax: 888-832-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: TRACY CLEARY
Title or Position: VICE PRESIDENT
Credential:
Phone: 281-462-7684