Provider Demographics
NPI:1003835265
Name:EAST TEXAS CARDIOVASCULAR LABS LLC
Entity Type:Organization
Organization Name:EAST TEXAS CARDIOVASCULAR LABS LLC
Other - Org Name:NACOGDOCHES SURGICAL CENTER LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRABHAKAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUNIGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-1844
Mailing Address - Street 1:1303 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4030
Mailing Address - Country:US
Mailing Address - Phone:936-560-1844
Mailing Address - Fax:936-564-5145
Practice Address - Street 1:1303 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4030
Practice Address - Country:US
Practice Address - Phone:936-560-1844
Practice Address - Fax:936-564-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008031261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH058AOtherBLUE CROSS PROVIDER #
TX171256401Medicaid
TX171256401Medicaid
TXASC228Medicare PIN