=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245606078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXELLABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2015
-----------------------------------------------------
Last Update Date | 01/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5130 S PECOS RD STE 2B
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-527-5501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3365 E FLAMINGO RD #3
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-6800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAB DIRECTOR
-----------------------------------------------------
Name | DR. QIYUAN PENG
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 702-527-5501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 8371LIC
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------