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General NPI Number Information
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NPI Number | 1174985139
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Entity Type | Organization
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Legal Business Name | HOMESTEAD NEURO DIAGNOSTICS
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Dates
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Enumeration Date | 03/28/2016
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Last Update Date | 03/28/2016
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Provider Practice Location Address
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Address Line | 8403 STATE HIGHWAY 151 STE 104 #111
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City | SAN ANTONIO
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State | TX
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Zip | 78245-2199
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Country | US
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Telephone | 832-469-1155
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Fax |
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Provider Business Mailing Address
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Address Line | 8403 STATE HIGHWAY 151 STE 104 #111
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City | SAN ANTONIO
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State | TX
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Zip | 78245-2199
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Country | US
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Telephone | 832-469-1155
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MR. CLIFTON ALBERT JACOB EDWARDS
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Credential | MHA, PMP, CPHQ
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Telephone | 832-469-1155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2472E0500X
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Taxonomy Name | EEG Technician
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License Number |
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License Number State |
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