MEDICARE: INTEGRATED HEALTH DIAGNOSTICS, LLC

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	:	1366833824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED HEALTH DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	10713 N RANCH ROAD 620
Second Line	:	BLDGE E STE 525
City	:	AUSTIN
State	:	TX
Zip	:	78726-1756
Country	:	US
Telephone Number	:	512-779-1376
Fax Number	:

Provider Business Practice Location Address
First Line	:	10713 N RANCH ROAD 620
Second Line	:	BLDGE E STE 525
City	:	AUSTIN
State	:	TX
Zip	:	78726-1756
Country	:	US
Telephone Number	:	512-779-1376
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MANI BALA
Credential	:	M.D.
Telephone Number	:	512-779-1376

Provider Enumeration Date	:	02/05/2015
Last Update Date	:	02/05/2015

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