Healthcare Provider Details

I. General information

NPI: 1447580758
Provider Name (Legal Business Name): PAMELA ADENUGA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 SOUTHEAST PKWY SUITE 106
ARLINGTON TX
76018-3605
US

IV. Provider business mailing address

1901 SOUTHEAST PKWY SUITE 106
ARLINGTON TX
76018-3605
US

V. Phone/Fax

Practice location:
  • Phone: 817-704-8081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number45D1091543
License Number StateTX

VIII. Authorized Official

Name: PAMELA ADENUGA
Title or Position: DIRECTOR
Credential:
Phone: 817-704-8081