Healthcare Provider Details

I. General information

NPI: 1447646393
Provider Name (Legal Business Name): LSA SA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8812 BROADWAY ST
SAN ANTONIO TX
78217-6318
US

IV. Provider business mailing address

8812 BROADWAY ST
SAN ANTONIO TX
78217-6318
US

V. Phone/Fax

Practice location:
  • Phone: 210-829-5662
  • Fax: 210-829-5630
Mailing address:
  • Phone: 210-829-5662
  • Fax: 210-829-5630

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: TERRY RIELY
Title or Position: ADMINISTRATOR
Credential:
Phone: 210-410-2563