Provider Demographics
NPI:1285679324
Name:PROFESSIONAL CLINICAL LABORATORY
Entity Type:Organization
Organization Name:PROFESSIONAL CLINICAL LABORATORY
Other - Org Name:PROLAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-776-5221
Mailing Address - Street 1:3020 WICHITA CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-1710
Mailing Address - Country:US
Mailing Address - Phone:866-776-5221
Mailing Address - Fax:817-568-1960
Practice Address - Street 1:7801 N ROBINSON AVE
Practice Address - Street 2:SUITE J11
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7726
Practice Address - Country:US
Practice Address - Phone:866-776-5221
Practice Address - Fax:817-560-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37D1054866291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200094750AMedicaid
OK200094750AMedicaid