Provider Demographics
NPI:1083001366
Name:NORTH LAKE LABORATORY LLC
Entity Type:Organization
Organization Name:NORTH LAKE LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-422-1009
Mailing Address - Street 1:1209 N AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-8600
Mailing Address - Country:US
Mailing Address - Phone:972-422-1009
Mailing Address - Fax:
Practice Address - Street 1:1209 N AVE
Practice Address - Street 2:STE 3
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-8600
Practice Address - Country:US
Practice Address - Phone:972-422-1009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2092364291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2092364OtherCLIA