Provider Demographics
NPI:1356655609
Name:NEUROLOGIC DIAGNOSTIC LABS
Entity Type:Organization
Organization Name:NEUROLOGIC DIAGNOSTIC LABS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:O
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-859-0378
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-3921
Mailing Address - Country:US
Mailing Address - Phone:972-859-0378
Mailing Address - Fax:
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-3921
Practice Address - Country:US
Practice Address - Phone:972-859-0378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID