MEDICARE: ASC 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	19D2242697	OTHER	LA	CLIA

General Provider Information

NPI Number	:	1780392589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASC DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	9742 SAINT VINCENT AVE STE 100
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7129
Country	:	US
Telephone Number	:	318-798-3306
Fax Number	:

Provider Business Practice Location Address
First Line	:	9742 SAINT VINCENT AVE STE 100
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7129
Country	:	US
Telephone Number	:	318-798-3306
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SOLE MEMBER
Name	:	RON KILGARLIN
Credential	:
Telephone Number	:	318-606-6020

Provider Enumeration Date	:	11/10/2022
Last Update Date	:	11/10/2022

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