Basic Information
| Provider Information | |||||||||
| NPI: | 1891187076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'FALLON | ||||||||
| FirstName: | IAN | ||||||||
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| Credential: | CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1577 | ||||||||
| Address2: | |||||||||
| City: | WALLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774841577 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 2816224381 | ||||||||
| Practice Location | |||||||||
| Address1: | 33518 HALEY RD # 1 | ||||||||
| Address2: | |||||||||
| City: | WALLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774845110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883442947 | ||||||||
| FaxNumber: | 2816224381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2015 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | 2897 | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.