MEDICARE: CLINICAL LABORATORY ASSOCIATES OF EL PASO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1073096178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL LABORATORY ASSOCIATES OF EL PASO LLC

Provider Business Mailing Address
First Line	:	11140 LA QUINTA PL STE 101B
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-5227
Country	:	US
Telephone Number	:	915-262-4300
Fax Number	:	915-262-0253

Provider Business Practice Location Address
First Line	:	11140 LA QUINTA PL STE 101B
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-5227
Country	:	US
Telephone Number	:	915-262-4300
Fax Number	:	915-262-0253

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	LAZARUS W. GUTIERREZ
Credential	:	MLT
Telephone Number	:	915-262-4300

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	09/13/2018

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