Provider Demographics
NPI:1306486394
Name:BRAINWAVE NEURODIAGNOSTICS LLC
Entity type:Organization
Organization Name:BRAINWAVE NEURODIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIBU
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAICKAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-686-9393
Mailing Address - Street 1:304 S COPPELL RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2417
Mailing Address - Country:US
Mailing Address - Phone:214-686-9393
Mailing Address - Fax:
Practice Address - Street 1:4541 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-1651
Practice Address - Country:US
Practice Address - Phone:214-686-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory