MEDICARE: ELITE CLINICAL LABORATORY 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	45D1061571	TX

General Provider Information

NPI Number	:	1942503412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE CLINICAL LABORATORY LLC

Provider Business Mailing Address
First Line	:	1800 ST JAMES PL STE 400
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77056
Country	:	US
Telephone Number	:	832-485-7155
Fax Number	:	832-436-1739

Provider Business Practice Location Address
First Line	:	1917 ASHLAND ST STE 120
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-3907
Country	:	US
Telephone Number	:	832-485-7155
Fax Number	:	832-436-1739

Authorized Official
Title or Position	:	OPERATIONS COORDINATOR
Name	:	MS. MICHELE LEVY POCHE
Credential	:
Telephone Number	:	832-485-7155

Provider Enumeration Date	:	12/06/2010
Last Update Date	:	08/27/2012

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