Provider Demographics
NPI:1326271859
Name:LBJ LABORATORY SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:LBJ LABORATORY SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-592-0343
Mailing Address - Street 1:2626 S LOOP W
Mailing Address - Street 2:SUITE 248
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2654
Mailing Address - Country:US
Mailing Address - Phone:713-592-0343
Mailing Address - Fax:713-592-0357
Practice Address - Street 1:2626 S LOOP W
Practice Address - Street 2:SUITE 248
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2654
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:2009-09-01
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246RP1900X291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory