Provider Demographics
NPI:1093848749
Name:MEDSTAT CLINICAL LABORATORY SERVICES
Entity Type:Organization
Organization Name:MEDSTAT CLINICAL LABORATORY SERVICES
Other - Org Name:MEDSTAT MOBILE LAB SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:LABORATORY DIRECTOR-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:NALL
Authorized Official - Suffix:
Authorized Official - Credentials:EMT, PHLEBOTOMIST
Authorized Official - Phone:800-808-6511
Mailing Address - Street 1:1401 QUAIL MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-7974
Mailing Address - Country:US
Mailing Address - Phone:800-808-6511
Mailing Address - Fax:800-621-0883
Practice Address - Street 1:1401 QUAIL MEADOW DR
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-7974
Practice Address - Country:US
Practice Address - Phone:800-808-6511
Practice Address - Fax:800-621-0883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCLIA# 45D0986849291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory