Provider Demographics
NPI:1255672176
Name:PROFESSIONAL CLINICAL LABORATORY, INC
Entity Type:Organization
Organization Name:PROFESSIONAL CLINICAL LABORATORY, INC
Other - Org Name:PROLAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:RENEA
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-776-5221
Mailing Address - Street 1:6660 DOUBLETREE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1128
Mailing Address - Country:US
Mailing Address - Phone:866-776-5221
Mailing Address - Fax:682-647-6238
Practice Address - Street 1:3020 WICHITA CT
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-1710
Practice Address - Country:US
Practice Address - Phone:866-776-5221
Practice Address - Fax:682-647-6238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D2050322291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286063701Medicaid
OK200094750AMedicaid
TX191954001Medicaid
LA1523402Medicaid
AL140312Medicaid
AR164542709Medicaid
TXCL5046OtherBLUE CROSS BLUESHIELD
MS00054521Medicaid
TX160698001Medicaid
690008760OtherRAILROAD MEDICARE