Provider Demographics
NPI:1881999654
Name:IMPULSE DIAGNOSTICS TX INC
Entity type:Organization
Organization Name:IMPULSE DIAGNOSTICS TX INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EUGENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELISSEEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-878-7372
Mailing Address - Street 1:4402 VANCE JACKSON RD STE 144
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5336
Mailing Address - Country:US
Mailing Address - Phone:210-481-9032
Mailing Address - Fax:210-568-4433
Practice Address - Street 1:4402 VANCE JACKSON RD STE 144
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5336
Practice Address - Country:US
Practice Address - Phone:210-481-9032
Practice Address - Fax:210-568-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX942246ZE0600X
TXP6398208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344230Medicare PIN