Healthcare Provider Details

I. General information

NPI: 1568070647
Provider Name (Legal Business Name): NORTH TEXAS NEURODIAGNOSTICS AND IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 VILLAGE CREEK DR STE 101
PLANO TX
75093-4431
US

IV. Provider business mailing address

PO BOX 6529
MCKINNEY TX
75071-5114
US

V. Phone/Fax

Practice location:
  • Phone: 844-212-5321
  • Fax: 214-594-9559
Mailing address:
  • Phone: 844-212-5321
  • Fax: 214-594-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: FRANK GRAY III
Title or Position: DIRECTOR
Credential:
Phone: 844-212-5321