MEDICARE: MISSION 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	45D2054829	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D2054829	OTHER	TX	CLIA

General Provider Information

NPI Number	:	1811376825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 197
Second Line	:
City	:	IOWA
State	:	LA
Zip	:	70647-0197
Country	:	US
Telephone Number	:	888-395-0423
Fax Number	:	888-409-5754

Provider Business Practice Location Address
First Line	:	10414 ROCKLEY RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77099-3524
Country	:	US
Telephone Number	:	281-617-7586
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LENA SHAH
Credential	:
Telephone Number	:	832-372-0397

Provider Enumeration Date	:	05/22/2015
Last Update Date	:	05/22/2015

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