MEDICARE: PROFESSIONAL CLINICAL LABORATORY INC

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	E0056	TX
2	291U00000X	Clinical Medical Laboratory	CLIA45D0942000	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992786743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL CLINICAL LABORATORY INC

Provider Business Mailing Address
First Line	:	3020 WICHITA CT
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76140-1710
Country	:	US
Telephone Number	:	866-776-5221
Fax Number	:	817-568-1960

Provider Business Practice Location Address
First Line	:	2718 SE LOOP 820
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76140-1011
Country	:	US
Telephone Number	:	866-776-5221
Fax Number	:	817-568-1960

Authorized Official
Title or Position	:	COO
Name	:	HOLLY R SHIELDS
Credential	:
Telephone Number	:	866-776-5221

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	12/03/2009

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