MEDICARE: NUVO DIAGNOSTICS, INC.

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

General Provider Information

NPI Number	:	1265544407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUVO DIAGNOSTICS, INC.

Provider Business Mailing Address
First Line	:	2909 LEMMON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-2311
Country	:	US
Telephone Number	:	214-828-4702
Fax Number	:	214-370-5130

Provider Business Practice Location Address
First Line	:	3409 OAK GROVE AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-2332
Country	:	US
Telephone Number	:	214-828-4702
Fax Number	:	214-370-5130

Authorized Official
Title or Position	:	LABORATORY MANAGER
Name	:	MR. CARL ANTHONY LAKE
Credential	:	MT, CHT
Telephone Number	:	214-828-4702

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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