=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639791007
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CCL LABS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2020
-----------------------------------------------------
Last Update Date | 05/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 TIBBETS DR STE 102
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76022-6900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-990-1335
-----------------------------------------------------
Fax | 855-631-0414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3720 E LA SALLE ST STE 104
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85040-3976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-990-1335
-----------------------------------------------------
Fax | 855-631-0414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. AYAZ AHMAD
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 844-990-1335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------