Provider Demographics
NPI:1366735771
Name:OMNI EEG LAB, INC.
Entity type:Organization
Organization Name:OMNI EEG LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:R EEG T
Authorized Official - Phone:877-334-5227
Mailing Address - Street 1:6162 E MOCKINGBIRD LN
Mailing Address - Street 2:SUITE 210A
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-2697
Mailing Address - Country:US
Mailing Address - Phone:877-334-5227
Mailing Address - Fax:214-550-8215
Practice Address - Street 1:6162 E MOCKINGBIRD LN
Practice Address - Street 2:SUITE 210A
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-2697
Practice Address - Country:US
Practice Address - Phone:877-334-5227
Practice Address - Fax:214-550-8215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory