Provider Demographics
NPI:1174985139
Name:HOMESTEAD NEURO DIAGNOSTICS
Entity type:Organization
Organization Name:HOMESTEAD NEURO DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:ALBERT JACOB
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MHA, PMP, CPHQ
Authorized Official - Phone:832-469-1155
Mailing Address - Street 1:8403 STATE HIGHWAY 151
Mailing Address - Street 2:STE 104 #111
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2199
Mailing Address - Country:US
Mailing Address - Phone:832-469-1155
Mailing Address - Fax:
Practice Address - Street 1:8403 STATE HIGHWAY 151
Practice Address - Street 2:STE 104 #111
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2199
Practice Address - Country:US
Practice Address - Phone:832-469-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEGGroup - Single Specialty