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NPI Code Detail

MEDICARE: LABORATORY SERVICES OF AMERICA LLC

MEDICARE: LABORATORY SERVICES OF AMERICA 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
1291U00000XClinical Medical Laboratory

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1GW168AOTHERNVMEDICARE PTAN

General Provider Information

NPI Number : 1871841130
Entity Type Code : Organization
Provider Name (Legal Business Name) : LABORATORY SERVICES OF AMERICA LLC
Provider Business Mailing Address
First Line : 3376 S EASTERN AVE
Second Line : STE 110
City : LAS VEGAS
State : NV
Zip : 89169-3380
Country : US
Telephone Number : 702-685-6777
Fax Number : 702-946-1401
Provider Business Practice Location Address
First Line : 3376 S EASTERN AVE
Second Line : STE 110
City : LAS VEGAS
State : NV
Zip : 89169-3380
Country : US
Telephone Number : 702-685-6777
Fax Number : 702-946-1401
Authorized Official
Title or Position : MANAGING PARTNER
Name : MR. RAKESH REDDY KOTHURU
Credential : MSHSA
Telephone Number : 702-685-6777
Provider Enumeration Date : 08/16/2012
Last Update Date : 05/07/2014

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