=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083946735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDRA POLOE DBA A1 LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2010
-----------------------------------------------------
Last Update Date | 03/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11500 NORTHWEST FWY SUITE 435
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77092-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-931-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 331515 11500 NORTHWEST FREEWAY STE.435
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77233-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-931-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. SANDRA POLOE
-----------------------------------------------------
Credential | CERTIFIED PROFESSION
-----------------------------------------------------
Telephone | 713-931-4848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 45D1107637
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------