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General NPI Number Information
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NPI Number | 1356638829
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Entity Type | Organization
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Legal Business Name | HERITAGE LABORATORY SYSTEMS
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Dates
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Enumeration Date | 07/06/2011
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Last Update Date | 08/01/2011
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Provider Practice Location Address
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Address Line | 15330 LBJ FWY SUITE 301 BOX 12
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City | MESQUITE
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State | TX
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Zip | 75150-1223
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Country | US
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Telephone | 972-698-0586
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Fax |
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Provider Business Mailing Address
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Address Line | 15330 LBJ FWY SUITE 301 BOX 12
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City | MESQUITE
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State | TX
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Zip | 75150-1223
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Country | US
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Telephone | 972-698-0586
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. RAYMOND EUGENE DAVIS JR.
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Credential | MT
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Telephone | 972-698-0586
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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 |
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License Number State |
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