Provider Demographics
NPI:1528588795
Name:PREMIER DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:PREMIER DIAGNOSTICS LLC
Other - Org Name:CENTENNIAL NEURODIAGNOSTICS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WEATHERWAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-646-8663
Mailing Address - Street 1:3838 OAK LAWN AVE STE 1000
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4511
Mailing Address - Country:US
Mailing Address - Phone:866-329-8177
Mailing Address - Fax:
Practice Address - Street 1:3838 OAK LAWN AVE STE 1000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4511
Practice Address - Country:US
Practice Address - Phone:469-646-8666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEGGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3875247Medicaid
FL104480100Medicaid