1093869489 NPI number — ANDRE LABORATORY INC

Table of content: (NPI 1093869489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093869489 NPI number — ANDRE LABORATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDRE 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:
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:
1093869489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1570 LOMALAND
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-328-6318
Provider Business Mailing Address Fax Number:
915-857-0492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1570 LOMALAND
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-328-6318
Provider Business Practice Location Address Fax Number:
915-857-0492
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDRADE
Authorized Official First Name:
LUIS
Authorized Official Middle Name:
Authorized Official Title or Position:
LABORATORY MANAGER
Authorized Official Telephone Number:
915-328-6318

Provider Taxonomy Codes

  • Taxonomy code: 246RM2200X , 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: 1616120 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000CL5123 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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