Provider Demographics
NPI:1518226521
Name:SOUTHWEST ELECTRODIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:SOUTHWEST ELECTRODIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAROQUE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:866-620-5987
Mailing Address - Street 1:PO BOX 794564
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75379-4564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16135 PRESTON RD STE 135
Practice Address - Street 2:BOX 21
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-3590
Practice Address - Country:US
Practice Address - Phone:866-620-5987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH67482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH6748OtherLICENSE