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General NPI Number Information
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NPI Number | 1407240740
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Entity Type | Organization
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Legal Business Name | EAST TEXAS REFERRAL AND TESTING, LLC
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Dates
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Enumeration Date | 03/25/2015
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Last Update Date | 09/19/2017
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Provider Practice Location Address
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Address Line | 9301 N CENTRAL EXPY 335D
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City | DALLAS
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State | TX
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Zip | 75231-0806
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Country | US
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Telephone | 972-630-6420
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Fax | 972-630-6421
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Provider Business Mailing Address
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Address Line | 9301 N CENTRAL EXPY 335D
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City | DALLAS
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State | TX
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Zip | 75231-0806
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Country | US
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Telephone | 972-630-6420
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Fax | 972-630-6421
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Authorized Official
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Title or Position | VICE PRESIDENT OF LEGAL
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Name | DEAN VISKOVICH
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Credential | ESQ.
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Telephone | 972-630-6443
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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 | 45D2090810
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License Number State | TX
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