1023364650 NPI number — CLINICAL PHYSICIANS PATHOLOGY LAB

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023364650 NPI number — CLINICAL PHYSICIANS PATHOLOGY LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICAL PHYSICIANS PATHOLOGY LAB
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:
1023364650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2022 MURCHISON DR # 124
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79902-3032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-532-9800
Provider Business Mailing Address Fax Number:
915-532-9801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 GEORGE DIETER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79936-7601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-849-5141
Provider Business Practice Location Address Fax Number:
915-849-4764
Provider Enumeration Date:
08/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
LAZARUS
Authorized Official Middle Name:
WILCOT
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
915-532-9800

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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