MEDICARE: SMALL GIANT 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	:	1619658572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALL GIANT LLC

Provider Business Mailing Address
First Line	:	720 E PARK BLVD STE 102
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75074-8844
Country	:	US
Telephone Number	:	925-314-5556
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 E PARK BLVD STE 102
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75074-8844
Country	:	US
Telephone Number	:	925-314-5556
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	POORNIMA GOWTHAMAN
Credential	:
Telephone Number	:	925-314-5556

Provider Enumeration Date	:	07/25/2023
Last Update Date	:	07/25/2023

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Directions to “SMALL GIANT LLC ” Practice Location

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