MEDICARE: BIOSTAT LABORATORIES, 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	42273804K	LA

General Provider Information

NPI Number	:	1437690849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIOSTAT LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	1651 E 70TH ST
Second Line	:	PMB 404
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5115
Country	:	US
Telephone Number	:	318-798-3306
Fax Number	:	318-798-3386

Provider Business Practice Location Address
First Line	:	9742 SAINT VINCENT AVE STE 200
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106
Country	:	US
Telephone Number	:	318-606-6050
Fax Number	:	318-606-6051

Authorized Official
Title or Position	:	CEO
Name	:	RON J. KILGARLIN JR.
Credential	:
Telephone Number	:	318-798-3306

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	05/24/2018

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