Provider Demographics
NPI:1225159510
Name:PRASANNA K ATHYALA
Entity Type:Organization
Organization Name:PRASANNA K ATHYALA
Other - Org Name:PERMIAN CLINICAL LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRASANNA
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:ATHYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-333-1837
Mailing Address - Street 1:415 N JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5124
Mailing Address - Country:US
Mailing Address - Phone:432-333-1837
Mailing Address - Fax:432-333-1856
Practice Address - Street 1:415 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5124
Practice Address - Country:US
Practice Address - Phone:432-333-1837
Practice Address - Fax:432-333-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1020447291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8556Medicare PIN