Provider Demographics
NPI:1215293360
Name:INNOVA NEURO MONITORING, LLC
Entity type:Organization
Organization Name:INNOVA NEURO MONITORING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRASE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-675-0905
Mailing Address - Street 1:PO BOX 21228
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1228
Mailing Address - Country:US
Mailing Address - Phone:214-675-0905
Mailing Address - Fax:214-317-4888
Practice Address - Street 1:4516 LOVERS LN # 331
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6925
Practice Address - Country:US
Practice Address - Phone:214-675-0905
Practice Address - Fax:214-317-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty