Provider Demographics
NPI:1356638829
Name:HERITAGE LABORATORY SYSTEMS
Entity Type:Organization
Organization Name:HERITAGE LABORATORY SYSTEMS
Other - Org Name:HERITAGE LABORATORY MESQUITE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MT
Authorized Official - Phone:972-698-0586
Mailing Address - Street 1:15330 LBJ FWY
Mailing Address - Street 2:SUITE 301 BOX 12
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1223
Mailing Address - Country:US
Mailing Address - Phone:972-698-0586
Mailing Address - Fax:
Practice Address - Street 1:15330 LBJ FWY
Practice Address - Street 2:SUITE 301 BOX 12
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1223
Practice Address - Country:US
Practice Address - Phone:972-698-0586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory