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General NPI Number Information
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NPI Number | 1255672176
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL CLINICAL LABORATORY, INC
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Dates
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Enumeration Date | 03/04/2013
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Last Update Date | 03/04/2013
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Provider Practice Location Address
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Address Line | 3020 WICHITA CT
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City | FT WORTH
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State | TX
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Zip | 76140-1710
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Country | US
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Telephone | 866-776-5221
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Fax | 682-647-6238
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Provider Business Mailing Address
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Address Line | 6660 DOUBLETREE AVE
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City | COLUMBUS
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State | OH
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Zip | 43229-1128
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Country | US
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Telephone | 866-776-5221
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Fax | 682-647-6238
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Authorized Official
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Title or Position | COO/VICE PRESIDENT
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Name | MRS. HOLLY RENEA SHIELDS
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Credential |
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Telephone | 866-776-5221
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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 | 36D2050322
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License Number State | OH
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