Provider Demographics
NPI:1467222844
Name:STAT TBI AND CONCUSSION DIAGNOSTICS
Entity Type:Organization
Organization Name:STAT TBI AND CONCUSSION DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-372-3765
Mailing Address - Street 1:1860 SANDY PLAINS RD
Mailing Address - Street 2:SUITE 200 PMB 2058
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066
Mailing Address - Country:US
Mailing Address - Phone:800-767-8903
Mailing Address - Fax:888-221-4798
Practice Address - Street 1:1100 LAKE ST STE LL56
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1034
Practice Address - Country:US
Practice Address - Phone:800-767-8903
Practice Address - Fax:888-221-4798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-05
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Multi-Specialty