MEDICARE: MOD 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D1036151	OTHER		CLIA

General Provider Information

NPI Number	:	1194968131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOD LAB

Provider Business Mailing Address
First Line	:	PO BOX 291209
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37229-1209
Country	:	US
Telephone Number	:	615-874-0410
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 GREENVILLE AVENUE
Second Line	:	SUITE 240
City	:	DALLAS
State	:	TX
Zip	:	75206-5037
Country	:	US
Telephone Number	:	615-874-0410
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JONATHAN OPPENHEIMER
Credential	:
Telephone Number	:	615-874-0410

Provider Enumeration Date	:	04/07/2009
Last Update Date	:	04/07/2009

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Directions to “MOD LAB ” Practice Location

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