1972829513 NPI number — LAKERIDGE LABORATORY INC

Table of content: (NPI 1972829513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972829513 NPI number — LAKERIDGE LABORATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKERIDGE LABORATORY INC
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:
LAKERIDGE LABORATORY
Provider Other Organization Name Type Code:
3
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:
1972829513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1712 E RIVERSIDE DR
Provider Second Line Business Mailing Address:
STE 232
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78741-1320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-913-6512
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5130 82ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79424-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-913-6512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
512-913-6512

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  45D0678293 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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