=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972970978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESTAR LABS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2015
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1651 N COLLINS BLVD STE 130
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-530-9050
-----------------------------------------------------
Fax | 469-530-9051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1651 N COLLINS BLVD STE 130
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-530-9050
-----------------------------------------------------
Fax | 469-530-9051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. FADEL ALSHALABI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-433-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 45D2098649
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------