Healthcare Provider Details

I. General information

NPI: 1619271541
Provider Name (Legal Business Name): MEDICAL DIAGNOSTICS NEUROLOGY SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 EXCHANGE AVE STE C
SCHERTZ TX
78154-2116
US

IV. Provider business mailing address

524 EXCHANGE AVE STE C
SCHERTZ TX
78154-2116
US

V. Phone/Fax

Practice location:
  • Phone: 210-566-2333
  • Fax: 210-497-5050
Mailing address:
  • Phone: 210-566-2333
  • Fax: 210-497-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT LANCE LAROQUE
Title or Position: CEO
Credential:
Phone: 210-854-9488