Provider Demographics
NPI:1053859884
Name:GLOBAL BRAIN EEG, LLC
Entity Type:Organization
Organization Name:GLOBAL BRAIN EEG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-328-3000
Mailing Address - Street 1:521 W SOUTHLAKE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6174
Mailing Address - Country:US
Mailing Address - Phone:817-328-3000
Mailing Address - Fax:817-328-3333
Practice Address - Street 1:521 W SOUTHLAKE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6174
Practice Address - Country:US
Practice Address - Phone:817-328-3000
Practice Address - Fax:817-328-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX409761001Medicaid