Provider Demographics
NPI:1558314567
Name:NEURODIAGNOSTIC TEX, LLC
Entity type:Organization
Organization Name:NEURODIAGNOSTIC TEX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-0809
Mailing Address - Street 1:PO BOX 1455
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-1455
Mailing Address - Country:US
Mailing Address - Phone:903-534-0809
Mailing Address - Fax:903-939-9149
Practice Address - Street 1:1356 OLD CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-7642
Practice Address - Country:US
Practice Address - Phone:903-534-0809
Practice Address - Fax:903-939-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTS049Medicare ID - Type UnspecifiedIDTF