MEDICARE: CLINICAL TESTING LABORATORIES, INC.

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	32D1086620	NM

General Provider Information

NPI Number	:	1609106756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL TESTING LABORATORIES, INC.

Provider Business Mailing Address
First Line	:	3655 RESEARCH DR
Second Line	:	MSC3ARP, BOX 30001
City	:	LAS CRUCES
State	:	NM
Zip	:	88003-1239
Country	:	US
Telephone Number	:	575-646-3465
Fax Number	:	575-646-6060

Provider Business Practice Location Address
First Line	:	3655 RESEARCH DR
Second Line	:	MSC3ARP, BOX 30001
City	:	LAS CRUCES
State	:	NM
Zip	:	88003-1239
Country	:	US
Telephone Number	:	575-646-3465
Fax Number	:	575-646-6060

Authorized Official
Title or Position	:	QUALITY MANAGER
Name	:	MR. STEFAN ALFRED LONG
Credential	:	CORP AGENT OF RECORD
Telephone Number	:	575-646-3465

Provider Enumeration Date	:	01/12/2010
Last Update Date	:	01/12/2010

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