Healthcare Provider Details

I. General information

NPI: 1205346954
Provider Name (Legal Business Name): SELECT DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E. FERNHURST DR, STE 111
KATY TX
77450-1431
US

IV. Provider business mailing address

8222 DOUGLAS AVE, STE 820
DALLAS TX
75225
US

V. Phone/Fax

Practice location:
  • Phone: 888-280-6332
  • Fax: 888-252-7043
Mailing address:
  • Phone: 469-646-8663
  • Fax: 888-252-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: KENNETH WEATHERWAX
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 469-646-8663