Healthcare Provider Details

I. General information

NPI: 1376592279
Provider Name (Legal Business Name): PROFESSIONAL CLINICAL LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 FAIRMONT PLZ
PEARL MS
39208-3424
US

IV. Provider business mailing address

3020 WICHITA CT
FORT WORTH TX
76140-1710
US

V. Phone/Fax

Practice location:
  • Phone: 866-776-5221
  • Fax: 817-568-1960
Mailing address:
  • Phone: 866-776-5221
  • Fax: 817-568-1960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: HOLLY R SHIELDS
Title or Position: COO
Credential:
Phone: 866-776-5221