=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033267596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOLAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 08/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3241 N 38TH ST
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-207-7812
-----------------------------------------------------
Fax | 866-624-4990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10331 N 24TH LN
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-207-7812
-----------------------------------------------------
Fax | 866-624-4990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. MARIO RODRIGUEZ JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-207-7812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------