Provider Demographics
NPI:1316196074
Name:LBJ LABORATORY SUPPORT SERVICES CORP.
Entity Type:Organization
Organization Name:LBJ LABORATORY SUPPORT SERVICES CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:ELIA
Authorized Official - Last Name:MONTELONGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-303-9415
Mailing Address - Street 1:2626 SOUTH LOOP WEST SUITE 240
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054
Mailing Address - Country:US
Mailing Address - Phone:713-303-9415
Mailing Address - Fax:713-665-8349
Practice Address - Street 1:2626 SOUTH LOOP WEST SUITE 240
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:713-592-0343
Practice Address - Fax:713-592-0357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX649296163W00000X
DC20.0075R05246RP1900X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty