Basic Information
Provider Information | |||||||||
NPI: | 1144672445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RED RIVER NEURODIAGNOSTICS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1141 N LOOP 1604 E # 105-612 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782321339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5080 SPECTRUM DRIVE SUITE 1100E | ||||||||
Address2: |   | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 75001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105982800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2016 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAROQUE | ||||||||
AuthorizedOfficialFirstName: | ROXANNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, CLIENT EXPERIENCE | ||||||||
AuthorizedOfficialTelephone: | 2105982801 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic | 2084N0600X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
No ID Information.