Provider Demographics
NPI:1851940209
Name:NEURODIAGNOSTICS SERVICES SOUTHWEST
Entity Type:Organization
Organization Name:NEURODIAGNOSTICS SERVICES SOUTHWEST
Other - Org Name:NEURODIAGNOSTICS SERVICES SOUTHWEST, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LANNETTE
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-286-1016
Mailing Address - Street 1:11900 N MACARTHUR BLVD STE E2
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1859
Mailing Address - Country:US
Mailing Address - Phone:405-286-1016
Mailing Address - Fax:405-242-2016
Practice Address - Street 1:2000 E LAMAR BLVD STE 608
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-7346
Practice Address - Country:US
Practice Address - Phone:405-286-1016
Practice Address - Fax:405-242-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEGGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1255736724Medicaid
MO1376923367Medicaid
CO1265803829Medicaid