1093174898 NPI number — CHARLEY STANLEY LABORATORIES LLC

Table of content: (NPI 1093174898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093174898 NPI number — CHARLEY STANLEY LABORATORIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLEY STANLEY LABORATORIES 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:
1093174898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E STACY RD
Provider Second Line Business Mailing Address:
STE 306-198
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75002-8734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-915-1800
Provider Business Mailing Address Fax Number:
682-503-6649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 N MAIN ST
Provider Second Line Business Practice Location Address:
STE 214
Provider Business Practice Location Address City Name:
EULESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76039-3655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-915-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VDOVYCHENKO
Authorized Official First Name:
CHARLOTTE
Authorized Official Middle Name:
BOATENG
Authorized Official Title or Position:
LAB DIRECTOR
Authorized Official Telephone Number:
817-915-1800

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  45D2108388 , 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)

  • Identifier: 45D2108388 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com