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General NPI Number Information
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NPI Number | 1114380102
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Entity Type | Organization
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Legal Business Name | NEUROVATIVE DIAGNOSTICS LLC
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Dates
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Enumeration Date | 03/29/2016
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Last Update Date | 01/25/2023
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Provider Practice Location Address
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Address Line | 16800 DALLAS PKWY STE 175
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City | DALLAS
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State | TX
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Zip | 75248-1941
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Country | US
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Telephone | 972-361-8040
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Fax |
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Provider Business Mailing Address
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Address Line | 16800 DALLAS PKWY STE 175
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City | DALLAS
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State | TX
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Zip | 75248-1941
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Country | US
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Telephone | 972-361-8040
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ANTHONY DARREL WAX
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Credential |
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Telephone | 214-802-1078
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 293D00000X
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Taxonomy Name | Physiological Laboratory
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License Number |
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License Number State |
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