MEDICARE: CISKA LABORATORIES, 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	:	1407046444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CISKA LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	5116 BISSONNET ST
Second Line	:	SUITE 327
City	:	BELLAIRE
State	:	TX
Zip	:	77401-4007
Country	:	US
Telephone Number	:	713-633-0600
Fax Number	:

Provider Business Practice Location Address
First Line	:	8300 HOMESTEAD RD
Second Line	:	SUITE 2
City	:	HOUSTON
State	:	TX
Zip	:	77028-2145
Country	:	US
Telephone Number	:	713-633-0600
Fax Number	:

Authorized Official
Title or Position	:	GENERAL SUPERVISOR
Name	:	BRYAN LIPSEN
Credential	:	M.D.
Telephone Number	:	713-635-6996

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	10/30/2007

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