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General NPI Number Information
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NPI Number | 1053723171
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE DIAGNOSTICS INC
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Dates
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Enumeration Date | 05/23/2014
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Last Update Date | 07/22/2021
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Provider Practice Location Address
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Address Line | 580 COMMERCE ST SUITE 150
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City | SOUTHLAKE
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State | TX
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Zip | 76092-9155
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Country | US
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Telephone | 817-421-7414
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Fax |
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Provider Business Mailing Address
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Address Line | 580 COMMERCE ST STE 150B
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City | SOUTHLAKE
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State | TX
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Zip | 76092-9214
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Country | US
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Telephone | 817-421-7414
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. DON STABLES JR.
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Credential |
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Telephone | 617-538-1748
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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 |
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License Number State |
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