MEDICARE: LEAN LABS MEDICAL SERVICES

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1174194682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEAN LABS MEDICAL SERVICES

Provider Business Mailing Address
First Line	:	4334 N LOOP 1604 W STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-3485
Country	:	US
Telephone Number	:	210-874-5326
Fax Number	:	210-874-5327

Provider Business Practice Location Address
First Line	:	4334 N LOOP 1604 W STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-3485
Country	:	US
Telephone Number	:	210-874-5326
Fax Number	:	210-874-5327

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MELISSA ELDER
Credential	:	RN
Telephone Number	:	210-874-5326

Provider Enumeration Date	:	07/06/2021
Last Update Date	:	07/06/2021

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