MEDICARE: UNIFIED LABORATORY SERVICES 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	:	1841546678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIFIED LABORATORY SERVICES LLC

Provider Business Mailing Address
First Line	:	512 N HAMPTON RD
Second Line	:	STE 261
City	:	DESOTO
State	:	TX
Zip	:	75115-4920
Country	:	US
Telephone Number	:	817-993-9857
Fax Number	:	817-294-4987

Provider Business Practice Location Address
First Line	:	6116 OAKBEND TRL
Second Line	:	STE 106
City	:	FT WORTH
State	:	TX
Zip	:	76132-3925
Country	:	US
Telephone Number	:	817-993-9857
Fax Number	:	817-294-3417

Authorized Official
Title or Position	:	PARTNER
Name	:	JEFF MADISON
Credential	:
Telephone Number	:	817-993-9857

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	11/01/2012

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Directions to “UNIFIED LABORATORY SERVICES LLC ” Practice Location

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