MEDICARE: ONE SOURCE DIAGNOSTIC TESTING

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1417983073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE SOURCE DIAGNOSTIC TESTING

Provider Business Mailing Address
First Line	:	2223 WORLEY DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3631
Country	:	US
Telephone Number	:	318-487-1884
Fax Number	:	318-487-1299

Provider Business Practice Location Address
First Line	:	2223 WORLEY DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3631
Country	:	US
Telephone Number	:	318-487-1884
Fax Number	:	318-487-1299

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RICHARD COOK
Credential	:
Telephone Number	:	318-487-1884

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	08/22/2020

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Directions to “ONE SOURCE DIAGNOSTIC TESTING ” Practice Location

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