MEDICARE: QUALITYCARE LABS, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D2079250	OTHER		CLIA

General Provider Information

NPI Number	:	1376044651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALITYCARE LABS, LLC

Provider Business Mailing Address
First Line	:	5401 N PORTLAND AVE STE 240
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2082
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3304 SE LOOP 820
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1113
Country	:	US
Telephone Number	:	844-381-7873
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	HUNTER HOGAN
Credential	:
Telephone Number	:	405-418-2929

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	02/22/2018

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