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General NPI Number Information
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NPI Number | 1932576931
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Entity Type | Organization
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Legal Business Name | FORTIS LABS LLC
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 08/25/2015
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Provider Practice Location Address
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Address Line | 1651 N COLLINS BLVD STE 135
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City | RICHARDSON
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State | TX
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Zip | 75080-3658
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Country | US
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Telephone | 469-530-9050
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Fax | 469-530-9051
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Provider Business Mailing Address
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Address Line | 1651 N COLLINS BLVD STE 135
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City | RICHARDSON
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State | TX
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Zip | 75080-3658
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Country | US
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Telephone | 469-530-9050
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Fax | 469-530-9051
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Authorized Official
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Title or Position | COO/CCO
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Name | MR. RON MANIPOL
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Credential | MLS, ASCP
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Telephone | 310-975-4797
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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 | 45D2098646
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License Number State | TX
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