Provider Demographics
NPI:1366477366
Name:EXTENDED LABORATORY SERVICES, L.P.
Entity Type:Organization
Organization Name:EXTENDED LABORATORY SERVICES, L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTRO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-556-1662
Mailing Address - Street 1:PO BOX 12913
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77217-2913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6160 SOUTH LOOP E
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-1010
Practice Address - Country:US
Practice Address - Phone:281-556-1662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8508Medicare ID - Type Unspecified