MEDICARE: ONE LAB DIAGNOSTICS, 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	45D2113785	OTHER	TX	CLIA

General Provider Information

NPI Number	:	1720438484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE LAB DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	3575 LONE STAR CIR STE 434
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8908
Country	:	US
Telephone Number	:	817-989-9479
Fax Number	:	817-989-9478

Provider Business Practice Location Address
First Line	:	3575 LONE STAR CIR STE 434
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-8908
Country	:	US
Telephone Number	:	817-989-9479
Fax Number	:	817-989-9478

Authorized Official
Title or Position	:	MANAGER
Name	:	KYLE COATES
Credential	:
Telephone Number	:	817-989-9479

Provider Enumeration Date	:	06/14/2016
Last Update Date	:	06/14/2016

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Directions to “ONE LAB DIAGNOSTICS, LLC ” Practice Location

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