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General NPI Number Information
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NPI Number | 1558808204
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Entity Type | Organization
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Legal Business Name | CONVERGENT DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 01/19/2017
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 718 S GREENVILLE AVE STE 100
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City | ALLEN
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State | TX
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Zip | 75002-3319
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Country | US
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Telephone | 214-501-5171
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Fax |
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Provider Business Mailing Address
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Address Line | 190 E STACY RD STE 306-198
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City | ALLEN
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State | TX
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Zip | 75002-8734
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MARC INGRAM
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Credential |
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Telephone | 214-501-5171
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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 | 45D2113081
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License Number State | TX
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