Provider Demographics
NPI:1003155979
Name:TRI-STATE TOXICOLOGY LLC
Entity Type:Organization
Organization Name:TRI-STATE TOXICOLOGY LLC
Other - Org Name:TRI-STATE TOXICOLOGY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:OMAR
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-571-1300
Mailing Address - Street 1:422 W NAKOMA ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2623
Mailing Address - Country:US
Mailing Address - Phone:210-571-1300
Mailing Address - Fax:210-519-2811
Practice Address - Street 1:422 W NAKOMA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2623
Practice Address - Country:US
Practice Address - Phone:210-571-1300
Practice Address - Fax:210-519-2811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE TOXICOLOGY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-12
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1691291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory