=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679951479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENCHMARK DIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2015
-----------------------------------------------------
Last Update Date | 01/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3020 CANTON ST
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75226-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-212-5737
-----------------------------------------------------
Fax | 214-427-8860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3020 CANTON ST
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75226-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-212-5737
-----------------------------------------------------
Fax | 214-427-8860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. ALLEN SULLIVAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-212-5737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZE0500X
-----------------------------------------------------
Taxonomy Name | EEG Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246ZE0600X
-----------------------------------------------------
Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------