=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861204117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SSDX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2025
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25814 BUDDE RD STE B1
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77380-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-364-3708
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 131752
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77393-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | LUIS ENRIQUE QUINTERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-854-0525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0007X
-----------------------------------------------------
Taxonomy Name | Molecular Genetic Pathology (Pathology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------