1407111024 NPI number — EAST TEXAS CLINICAL LABORATORY LLC

Table of content: MS. DIANELIS OJEDA RODRIGUEZ APRN (NPI 1609512987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407111024 NPI number — EAST TEXAS CLINICAL LABORATORY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS CLINICAL LABORATORY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407111024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9301 NORTH CENTRAL EXPRESSWAY
Provider Second Line Business Mailing Address:
TOWER 2 SUITE 335A
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-630-6400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9301 NORTH CENTRAL EXPRESSWAY
Provider Second Line Business Practice Location Address:
TOWER 2 SUITE 335A
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-630-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
VISKOVICH
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF COMPLIANCE
Authorized Official Telephone Number:
972-630-6400

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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