MEDICARE: LAB DIRECT, 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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	J2242	TX

General Provider Information

NPI Number	:	1568730513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAB DIRECT, LLC

Provider Business Mailing Address
First Line	:	134 ROSEDALE
Second Line	:
City	:	ATHENS
State	:	TX
Zip	:	75751-3625
Country	:	US
Telephone Number	:	903-675-0080
Fax Number	:	903-675-0081

Provider Business Practice Location Address
First Line	:	134 ROSEDALE
Second Line	:
City	:	ATHENS
State	:	TX
Zip	:	75751-3625
Country	:	US
Telephone Number	:	903-675-0080
Fax Number	:	903-675-0081

Authorized Official
Title or Position	:	PATHOLOGIST
Name	:	DR. JAMES RICHARD OGBURN JR.
Credential	:	MD
Telephone Number	:	903-675-0080

Provider Enumeration Date	:	12/06/2011
Last Update Date	:	12/06/2011

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