Provider Demographics
NPI:1245409457
Name:ONE SOURCE TOXICOLOGY LABORATORY INC
Entity Type:Organization
Organization Name:ONE SOURCE TOXICOLOGY LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMEO
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAUREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-920-2559
Mailing Address - Street 1:1209 GENOA RED BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504
Mailing Address - Country:US
Mailing Address - Phone:713-920-2559
Mailing Address - Fax:281-998-8587
Practice Address - Street 1:1209 GENOA RED BLUFF RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504
Practice Address - Country:US
Practice Address - Phone:713-920-2559
Practice Address - Fax:281-998-8587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE SOURCE TOXICOLOGY LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-22
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1014951291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL1016Medicare PIN