Provider Demographics
NPI:1942661277
Name:MISSISSIPPI NEURODIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:MISSISSIPPI NEURODIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:CONOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-995-8416
Mailing Address - Street 1:4545 FULLER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6509
Mailing Address - Country:US
Mailing Address - Phone:469-995-8416
Mailing Address - Fax:866-279-4704
Practice Address - Street 1:4600 FULLER DR STE 275
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6551
Practice Address - Country:US
Practice Address - Phone:469-995-8416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIANCE FAMILY OF COMPANIES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-15
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic