MEDICARE: ELITE DIAGNOSTIC LABORATORY

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	:	1578347860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE DIAGNOSTIC LABORATORY

Provider Business Mailing Address
First Line	:	904 JOLEN CT
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-5326
Country	:	US
Telephone Number	:	323-578-2029
Fax Number	:

Provider Business Practice Location Address
First Line	:	6909 GRAND BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2203
Country	:	US
Telephone Number	:	323-578-2029
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ERAN WEINBERG
Credential	:
Telephone Number	:	323-578-2029

Provider Enumeration Date	:	08/21/2023
Last Update Date	:	06/30/2025

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