Provider Demographics
NPI:1114380102
Name:NEUROVATIVE DIAGNOSTICS LLC
Entity type:Organization
Organization Name:NEUROVATIVE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DARREL
Authorized Official - Last Name:WAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-802-1078
Mailing Address - Street 1:16800 DALLAS PKWY STE 175
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1941
Mailing Address - Country:US
Mailing Address - Phone:972-361-8040
Mailing Address - Fax:
Practice Address - Street 1:16800 DALLAS PKWY STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1941
Practice Address - Country:US
Practice Address - Phone:972-361-8040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory