MEDICARE: FORENSIC 360 LABORATORY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZF0201X	Forensic Pathology Physician

General Provider Information

NPI Number	:	1093363228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORENSIC 360 LABORATORY

Provider Business Mailing Address
First Line	:	1801 N HAMPTON RD STE 270
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-2399
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 N HAMPTON RD STE 270
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-2399
Country	:	US
Telephone Number	:	463-222-1200
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	CINDY JOHNSON
Credential	:
Telephone Number	:	469-222-1200

Provider Enumeration Date	:	08/30/2019
Last Update Date	:	08/30/2019

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Directions to “FORENSIC 360 LABORATORY ” Practice Location

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