MEDICARE: MY HEALTH LAB

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	291U00000X	Clinical Medical Laboratory	45D1042857	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D1042857	OTHER	TX	CLIA ID #

General Provider Information

NPI Number	:	1164682175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY HEALTH LAB

Provider Business Mailing Address
First Line	:	PO BOX 14182
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77221-4182
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4106 TIDEWATER DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77045-4338
Country	:	US
Telephone Number	:	713-517-1875
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOHN D. SADLER JR.
Credential	:	MEDICAL TECHNOLOGIST
Telephone Number	:	713-517-1875

Provider Enumeration Date	:	06/12/2008
Last Update Date	:	03/26/2015

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