MEDICARE: OMNI NEURO DIAGNOSTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1417497025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI NEURO DIAGNOSTICS

Provider Business Mailing Address
First Line	:	3900 S STONEBRIDGE DR.
Second Line	:	SUITE 1501
City	:	MCKINNEY
State	:	TX
Zip	:	75070
Country	:	US
Telephone Number	:	214-396-7227
Fax Number	:	469-453-3192

Provider Business Practice Location Address
First Line	:	3900 S STONEBRIDGE DR.
Second Line	:	SUITE 1501
City	:	MCKINNEY
State	:	TX
Zip	:	75070
Country	:	US
Telephone Number	:	214-396-7227
Fax Number	:	469-453-3192

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. NICHOLAS KOBAKOF
Credential	:
Telephone Number	:	214-396-7227

Provider Enumeration Date	:	03/01/2017
Last Update Date	:	03/30/2018

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