MEDICARE: LSA SA 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	:	1447646393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LSA SA LLC

Provider Business Mailing Address
First Line	:	8812 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-6318
Country	:	US
Telephone Number	:	210-829-5662
Fax Number	:	210-829-5630

Provider Business Practice Location Address
First Line	:	8812 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-6318
Country	:	US
Telephone Number	:	210-829-5662
Fax Number	:	210-829-5630

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TERRY RIELY
Credential	:
Telephone Number	:	210-410-2563

Provider Enumeration Date	:	04/07/2015
Last Update Date	:	04/07/2015

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