1255672176 NPI number — PROFESSIONAL CLINICAL LABORATORY, INC

Table of content: (NPI 1255672176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255672176 NPI number — PROFESSIONAL CLINICAL LABORATORY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL CLINICAL 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:
6
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:
1255672176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6660 DOUBLETREE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43229-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-776-5221
Provider Business Mailing Address Fax Number:
682-647-6238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 WICHITA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76140-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-776-5221
Provider Business Practice Location Address Fax Number:
682-647-6238
Provider Enumeration Date:
03/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SHIELDS
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
RENEA
Authorized Official Title or Position:
COO/VICE PRESIDENT
Authorized Official Telephone Number:
866-776-5221

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  36D2050322 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 286063701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200094750A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 191954001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1523402 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 140312 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 164542709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL5046 . This is a "BLUE CROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00054521 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160698001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690008760 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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