MEDICARE: ROLLING HILLS LABORATORIESS 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	:	1760921530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROLLING HILLS LABORATORIESS LLC

Provider Business Mailing Address
First Line	:	10847 SANDEN DR
Second Line	:	STE 101
City	:	DALLAS
State	:	TX
Zip	:	75238-5358
Country	:	US
Telephone Number	:	214-888-6976
Fax Number	:	888-845-7740

Provider Business Practice Location Address
First Line	:	1337 VIRGINIA ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-3011
Country	:	US
Telephone Number	:	214-888-6976
Fax Number	:	888-845-7740

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN DIXON III
Credential	:
Telephone Number	:	214-888-6976

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/16/2017

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