Healthcare Provider Details

I. General information

NPI: 1710282686
Provider Name (Legal Business Name): ST MICHAELS LABS LAS VEGAS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 SIENA HEIGHTS DR SUITE 200
HENDERSON NV
89052-4167
US

IV. Provider business mailing address

PO BOX 924109 SUITE 200
HOUSTON TX
77292-4109
US

V. Phone/Fax

Practice location:
  • Phone: 702-824-9655
  • Fax: 702-889-4213
Mailing address:
  • Phone: 713-586-6778
  • Fax: 713-586-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number29D2008291
License Number StateNV

VIII. Authorized Official

Name: JO ANN JOHNSON
Title or Position: CREDENTIALING ASSISITANT
Credential:
Phone: 713-586-6778