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General NPI Number Information
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NPI Number | 1992982151
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Entity Type | Organization
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Legal Business Name | CHARLOTTE VDOVYCHENKO
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Dates
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Enumeration Date | 01/29/2008
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Last Update Date | 11/19/2008
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Provider Practice Location Address
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Address Line | 703 MCKINNEY AVE
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City | DALLAS
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State | TX
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Zip | 75202-1007
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Country | US
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Telephone | 817-915-1800
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Fax | 682-503-6649
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Provider Business Mailing Address
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Address Line | PO BOX 59
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City | EULESS
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State | TX
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Zip | 76039-0059
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Country | US
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Telephone | 817-915-1800
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Fax | 682-503-6649
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. CHARLOTTE B VDOVYCHENKO
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Credential | M(ASCP)
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Telephone | 817-915-1800
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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 | 45D1073121
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License Number State | TX
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