MEDICARE: BETA DIAGNOSTIC LABS 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457003329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETA DIAGNOSTIC LABS LLC

Provider Business Mailing Address
First Line	:	7200 WASHINGTON AVE STE 104
Second Line	:
City	:	MT PLEASANT
State	:	WI
Zip	:	53406-6516
Country	:	US
Telephone Number	:	262-583-0068
Fax Number	:	262-583-0079

Provider Business Practice Location Address
First Line	:	7200 WASHINGTON AVE STE 104
Second Line	:
City	:	MT PLEASANT
State	:	WI
Zip	:	53406-6516
Country	:	US
Telephone Number	:	262-583-0068
Fax Number	:	262-583-0079

Authorized Official
Title or Position	:	OWNER
Name	:	TOM C TOUSIS
Credential	:
Telephone Number	:	262-583-0068

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	08/08/2022

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