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General NPI Number Information
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NPI Number | 1518226521
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Entity Type | Organization
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Legal Business Name | SOUTHWEST ELECTRODIAGNOSTIC CENTER LLC
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Dates
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Enumeration Date | 05/10/2012
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 16135 PRESTON RD STE 135 BOX 21
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City | DALLAS
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State | TX
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Zip | 75248-3590
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Country | US
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Telephone | 866-620-5987
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 794564
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City | DALLAS
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State | TX
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Zip | 75379-4564
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. HENRY G RAROQUE JR.
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Credential | MD
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Telephone | 866-620-5987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | H6748
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License Number State | TX
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