1801212766 NPI number — ADVANTA LABS, LLC

Table of content: (NPI 1801212766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801212766 NPI number — ADVANTA LABS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTA LABS, 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:
1801212766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 S NOLEN DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-9194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-488-8000
Provider Business Mailing Address Fax Number:
817-488-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 S NOLEN DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-9194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-488-8000
Provider Business Practice Location Address Fax Number:
817-488-8001
Provider Enumeration Date:
03/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HADIAN
Authorized Official First Name:
YUSUF
Authorized Official Middle Name:
M
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
817-488-8000

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)

  • Identifier: 45D2072790 . This is a "CLIA NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 3715898-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108300700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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