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General NPI Number Information
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NPI Number | 1003155979
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Entity Type | Organization
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Legal Business Name | TRI-STATE TOXICOLOGY LLC
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Dates
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Enumeration Date | 02/12/2013
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Last Update Date | 08/08/2022
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Provider Practice Location Address
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Address Line | 422 W NAKOMA ST
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City | SAN ANTONIO
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State | TX
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Zip | 78216-2623
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Country | US
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Telephone | 210-571-1300
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Fax | 210-519-2811
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Provider Business Mailing Address
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Address Line | 422 W NAKOMA ST
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City | SAN ANTONIO
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State | TX
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Zip | 78216-2623
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Country | US
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Telephone | 210-571-1300
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Fax | 210-519-2811
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRANDON OMAR GOMEZ
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Credential |
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Telephone | 210-571-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | J1691
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License Number State | TX
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