Healthcare Provider Details

I. General information

NPI: 1861031783
Provider Name (Legal Business Name): KER ROCK ISLAND, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15950 DALLAS PKWY STE 400
DALLAS TX
75248-6628
US

IV. Provider business mailing address

MSC 927 PO BOX 660707
DALLAS TX
75266-0707
US

V. Phone/Fax

Practice location:
  • Phone: 469-334-4307
  • Fax:
Mailing address:
  • Phone: 469-334-4307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: FELICIA ALDERETE
Title or Position: LEGAL OPERATIONS MANAGER
Credential:
Phone: 210-598-2801