Healthcare Provider Details

I. General information

NPI: 1174888184
Provider Name (Legal Business Name): FOUR STATES NEURO TECH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4516 LOVERS LN # 331
DALLAS TX
75225-6925
US

IV. Provider business mailing address

PO BOX 702620
TULSA OK
74170-2620
US

V. Phone/Fax

Practice location:
  • Phone: 214-675-0905
  • Fax: 214-317-4888
Mailing address:
  • Phone: 214-675-0905
  • Fax: 214-317-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name: TRASE MAHAN
Title or Position: MANAGER
Credential:
Phone: 214-675-0905