=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306213756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED LABORATORY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 05/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E PEYTON ST
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-0200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-487-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 E PEYTON ST
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-0200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-487-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | TIMOTHY MCCLURE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-487-0598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------