MEDICARE: HALSTEAD MONITORING LLC

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	:	1629457387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HALSTEAD MONITORING LLC

Provider Business Mailing Address
First Line	:	PO BOX 890161
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73189-0161
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2226 SHADOWLAKE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7440
Country	:	US
Telephone Number	:	405-622-3827
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JUSTIN BOMAN
Credential	:
Telephone Number	:	405-622-3827

Provider Enumeration Date	:	05/27/2015
Last Update Date	:	05/27/2015

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