Healthcare Provider Details

I. General information

NPI: 1720965619
Provider Name (Legal Business Name): AXONBLU DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 08/20/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3548 MCBROOM ST
DALLAS TX
75212-2346
US

IV. Provider business mailing address

3548 MCBROOM ST
DALLAS TX
75212-2346
US

V. Phone/Fax

Practice location:
  • Phone: 817-422-1614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CALEB J HINTON
Title or Position: PRESIDENT
Credential:
Phone: 817-422-1614