=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174861678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY LABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2013
-----------------------------------------------------
Last Update Date | 01/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20476 THOMPSON RD
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78593-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-569-8996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20476 THOMPSON RD
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78593-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-569-8996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ESTELLA MUNOZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-569-8996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 2013-00000313
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------