=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053770057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHTH HOLDINGS 2015-1
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2016
-----------------------------------------------------
Last Update Date | 08/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3101 CHURCHILL DR SUITE 115-D
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75022-2799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-809-6817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3101 CHURCHILL DR SUITE 115D
-----------------------------------------------------
City | FLOWER MOUND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75022-2799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAB DIRECTOR
-----------------------------------------------------
Name | JEFFREY EMBREY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 817-809-6817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 45D2107660
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------